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A TREATISE
W.a.YnitJiihh<ir.
DISEASES OF THE HEART
GREAT VESSELS,
AND ON THE
AFFECTIONS WHICH MAY BE MISTAKEN FOR THEM
comprising the
author's view of the physiology of the heart's action and sounds as demonstrated
by his experiments on the motions and sounds in 1830,
and on the sounds in 1834-5.
BY J. HOPE, M. D. F. R. S.
Of St. George's Hospital ; formerly Senior Physician to the St. Marylebone Infirmary ; Extraordi
nary Member, and formerly President, of the Royal Medical Society of Edinburgh, &c.
FIRST AMERICAN FROM THE THIRD LONDON EDITION.
WITH NOTES AND A DETAIL OF RECENT EXPERIMENTS,
BY C. W. PENNOCK, M. D.
\ltending Physiciaji to The Philadelphia. Hospital, Blockley.
PHILADELPHIA:
HASWELT, & JOHNSON, NINTH AND CHESTNUT STREET.
1842.
H*
at
Entered, according to the Act of Congress, in tiie year 1842, by Haswell & Johnson?
in the Clerk's Office of the District Court of the Eastern District of Pennsylvania,
Gill.
TO DR. ALEXANDER HANNAY, GLASGOW.
My Dear Hannay —
Little less than twenty years have elapsed since we studied auscultation
together as house physicians to the Edinburgh Infirmary. At that time,
there were few auscultators and many opponents in the land. We have
lived to see these circumstances reversed ; and to you, whose zeal and
talents have contributed so powerfully to the change, it must be gratifying
to behold this once suspected department of medical science recognised as
one of the greatest of discoveries, cultivated with avidity by all classes of
our profession, and — what is still better — extensively alleviating the suf-
ferings of our fellow-creatures.
To you I am indebted for having first drawn my attention to the sub-
ject: to you I wish to inscribe this trilling result of my labours, and
inadequate testimony of my esteem.
Hinc (omne)principium, hue refer exitum.
Always, my dear Hannay,
Your sincere friend,
J. HOPE.
13, Lower Seymour-street,
May 11, 1839.
PREFACE
TO THE THIRD EDITION
The addition of one third of new matter to the present
volume, and the care with which the whole has been
revised and corrected, will, I trust, sufficiently prove my
respect for the favourable opinion of my professional
brethren, as evinced, not in this country only, but also on
the European and American continents, by the sale of no
less than six or seven editions and translations in as many
years.
The additions, including', I hope, some useful original
matter, though they pervade every part of the work, will
be found principally under the following heads : —
1. The natural sounds of the heart.1 2. The sound of
1 My labours on this subject have been appropriated by a certain gentle-
man, who, however, has not the most remote pretensions to them. He says,
in the Med. Gaz. for September 1835, p. S18, "In the last number of the
Med. Gaz. there is an account of my experiments on the sounds of the
heart, extracted from an appendix to Dr. Hope's work on the Diseases of the
Heart. The statement of the experiments is correct, as Dr. Hope was pre-
sent at the greater part (the whole) of them, and / also sent him the ori-
ginal notes." For the facts, see p. 52, and the foot-note.
Several writers and reviewers have been led into the error of ascribing
these experiments to the individual alluded to: e. g. Professor Milller, in
the translation of his Physiology, part iv. p. 176, and Appendix, p. 1: Dr.
Alison, in his Supplement to his Outlines of Physiology, p. 18, 1836, &c.
VI PREFACE.
costal percussion, with or without tinnitus (Laennec's
Cliquetis). 3. Murmurs from valvular disease, and the
whole subject of particular valvular diagnosis, which will
now, I confidently hope, be found one of the most simple
and easy departments of auscultation. 4. Murmurs of the
heart and arteries independent of organic disease. 5.
Venous murmurs. 6. Musical murmurs. 7. Abdominal
murmurs, both connected with pregnancy, and otherwise.
8. Tremour or thrill of the heart, arteries, and veins.
9. Signs, general and physical, of pericarditis and endo-
pericarditis. 10. Connection of diseases of the heart with
apoplexy, palsy, &c. 11. Partial dilatation or real aneu-
rism of the heart. 12. The signs, physical and general,
and the pulse of softening. 13. Signs of adipose disease
of the heart. 14. Aneurisms of the aorta bursting into
the pulmonary artery and the right ventricle. 15. Ab-
dominal aneurisms. 16. Anaemic, nervous, dyspeptic,
plethoric, bilious, and other sympathetic affections of the
heart, with their diagnosis. 17. Displacements. 18. The
pulses of disease of the heart.
To the complaints made by some, that additions and
alterations so considerable have been so tardily published,1
though I have habitually taught most of them to my class
and in the hospital for several years, I can only reply by
pleading my utter inability, even if there had been the
inclination, to devote more than an average share of atten-
tion to any one subject ; — an inability which rests upon all
those who, to the private distractions of a laborious profes-
sion, add the onerous duties of hospital physicians and
teachers of the practice of medicine. I can, indeed, truly
say, with Senac and others, that I have worked slowly
and painfully, inter "tsedia et labores," in fragments of
time hardly redeemed from excessive professional engage-
ments.
I have studied brevity to the utmost, my object always
1 Except the experiments on the sounds, published in the Appendix to
the previous edition, in April, 1335.
PREFACE. Vll
having been, to offer the pith of the whole subject in the
smallest possible compass. For this reason, I have avoided
the multiplication of prolix cases, — offering no new ones
except for the illustration of new points or doctrines. As,
however, I have sometimes referred to numbers so large
as might seem incredible without explanation, it may be
proper to state, once for all, that, out of upwards of 15,000
hospital in and out patients, w^hom I have treated during
the last eight years, about seven per cent., as near as I
can judge from a rough calculation,1 have laboured under
organic disease of the heart, — making a total of 1050
cases, exclusive of those occurring in private practice.
I have in several instances transferred to their proper
sources discoveries which, in the first edition, I imagined
to have belonged to myself. Any similar oversights in
the present edition I shall be happy to rectify, if the
authors will oblige me with the information.
I have, on the same principle, and, I trust, with perfect
good feeling, ventured to reclaim for my countrymen and
self a number of discoveries, which an eminent French
writer, probably from unacquaintance with the English
language and medical literature, has imagined to have
emanated from himself.
Finally, I have added a few plates, which I trust will
be found convenient.
I have to express my obligations to Mr. James Freeman
for the excellent Alphabetical Index.2
J. H.
1 If I have leisure hereafter to sort these eases, I trust to give the exact
per centage.
2 In an Appendix prefixed to this Index will be found the important
autopsies of the cases of V . . . ., Esq.. and Goff.
PREFACE
BY THE AMERICAN EDITOR.
In complying with the request to add notes to the first
American Edition of Dr. Hope's work on the Diseases of
the Heart, the object of the Editor has been twofold; —
First, to present such views as were regarded by him as
being important, in order more fully to elucidate the pre-
sent state of knowledge respecting the pathology of the
central organ of the circulation; and, secondly, whilst en-
deavouring to supply what he might regard as deficien-
cies, not to give superfluous or redundant matter, and thus
render the work inconveniently voluminous.
In carrying out these views, it will be seen that the
Editor has not restricted himself to the introduction of
purely original matter, but, as he was anxious to do full
justice to the eminent pathologists with whom any inge-
nious or valuable views may have originated, he has pre-
ferred using their own language, rather than incur the risk
of conveying wrong impressions, either by condensing it,
or by clothing their thoughts in other words. Hence, it
will be found, that copious extracts from the writings of
that most talented and ingenious pathologist, Dr. C. J. B.
Williams, are not unfrequent. The valuable investiga-
tions of M. Bizot, respecting the dimensions of the heart,
have been given in detail. Views respecting certain pa-
thological facts derived from the Editor's observations
have also been introduced, and a previously undescribed
form of Dissecting Aneurism has been illustrated by se-
PREFACE.
veral cases. It has also been thought proper to present
the result of " the Experiments on the Heart's Action"
which have been instituted since the death of the lamented
Author; and as it was supposed that some interest might
be had in those performed in this country, the Experi-
ments which were made by the Editor and his friend Dr.
E. M. Moore, of Rochester, N. Y., have been introduced.
The additional matter presented in this edition is in small
type within brackets, and bears the initial of the name of
the Editor.
C. W. P.
Philadelphia, )
July 1st, 1842. 5
CONTENTS.
Introduction Page 17
PART I.
Anatomy and Physiology of the
Heart.
Page
CHAPTER I.
Anatomy of the Heart 29
{Situation of the heart 3D
Percussion of the heart 33
Causes which prevent dulness on
percussion 35
CHAPTER II.
On the Action and Sounds of the
Heart 35
Sect. 1. Ei jx rim mtul Researches on
the Action of the Heart 35
Experiments performed on rabbits
and frogs, July 31, 183!) 3G
Experiments, Aug. 21, 1830 38
Conclusions on the motions of the
heart 42
Conclusions on the sounds 4'3
Conclusions on the rhythm. 43
Experiments repeated, Aujr. 10,
1831 44
Sect. II. Experimental, Physiological
and Pathological Researches on
the Sounds of the Heart 48
Experiments, Series i 53
, Series ii 55
, Series iii 56
Conclusions from the whole of the
experiments on the sounds 71
a. Conclusions on the first sound 71
How far it is caused by muscular
extension 73
How far it is caused by bruit mus-
culaire 75
How far it is caused by extension of
the auricular valves 76
I. Conclusions on the second sound. 79
c. Conclusions on murmurs artificial-
ly produced 80
Erroneous or defective Theories of
the Sounds of the Heart 80
13— c
CHAPTER III.
Page
Physiological Phenomena of the
Heart's Action and Sounds
founded on the foregoing Re-
searches 83
1. The phenomena of the heart's ac-
tion in the order of their occur-
rence 83
2. Causes, mechanism and objects of
the motions 84
3. Causes and mechanism of the
sounds 89
First principle of the heart's mo-
tion 91
CHAPTER IV.
Pathological Phenomena of the
Heart's Action and Sounds 92
Sect. I. Modifications of the Motions
and Sounds by Hypertrophy and
Dilatation 92
Simple hypertrophy 92
Simple dilatation 93
Hypertrophy with dilatation 94
Sect. II. Murmurs produced by Val-
vular Disease 95
Aortic valves; 1. Systolic murmur. 96
2. Diastolic murmur 98
Pulmonic valves; 1. Systolic mur-
mur 100
; 2. Diastolic mur-
mur 101
Mitral valve; 1. Systolic murmur 101
; 2. Diastolic murmur 103
Tricuspid valve; 1. Systolic murmur 104
; 2. Diastolic murmur 104
Mechanism and varieties of valvu-
lar murmurs 105
Continuous murmur in the heart. . 108
Pitch or key of valvular murmurs 109
Musical murmurs in the heart. ... 110
Summary of conclusions on mur-
murs in the heart 112
Situations in which murmurs of
the respective valves are most
audible 114
1* hope
Xll
CONTENTS.
Page
Sect. 111. Murmur from Hypertrophy
with Dilatation, and its Mecha-
nism 117
Sect. IV. Murmurs in the Heart and
Arteries independent of Organic
Disease 118
Laennec's views incorrect 118
Author's views, with proofs 120
Experiments on Dogs 122
Recapitulation of causes 124
Author's views applied to mur-
murs, a, from compression of ar-
teries 126
b, From loss of blood 127
c, From anaemia, &c 127
d, From arterial varix 128
Musical murmurs not arterial, but
venous 129
Sect. V. Venous or Continuous Mur-
mur, Hum, and Musical Notes. ..129
Venous murmur 129
Musical venous murmur 136
Constitutional causes of venous
murmurs 140
Sect. VI. Purring Tremor or Thrill
of the Heart and Arteries 141
1. Jn the heart 141
2. In the arteries 142
3. Inorganic tremors in the arteries 142
Inorganic tremor in the veins. .. 539
CHAPTER V.
Auscultation applied to Preg-
nancy 143
1. The double beat of the foetal heart 143
2. The murmur usually called utero-
placental 146
Cases illustrative of murmurs oc-
curring in pregnancy, &c 148
Seat of (he murmur of pregnancy. 153
Practical conclusions 155
PART II.
Inflammatory Affections of the
Heart and Great Vessels 156
CHAPTER L
On Pericarditis 156
Sect. I. Anatomical Characters of
acute Pericarditis 156
1. Preternatural rednes3 of the peri-
cardium 156
2. Coagulable lymph adhering to the
surface of the pericardium 158
Object of adhesion 159
Process of adhesion 160
Opake white spots on the surface
of the heart 161
Analogous transformations of false
membrane 162
Page
3. Fluid effused within the cavity of
the pericardium 162
Anatomical characters of chronic
pericarditis 163
Sect. II. Signs and Diagnosis of acute
Pericarditis 164
1, General signs 165
Signs of amelioration 1 72
2. Physical signs. Percussion 173
Impulse. Sounds.. 174
Attrition-murmurs. . , 175
Murmurs of coexistent endocardi-
tis 180
Diagnosis of valvular from attrition-
murmurs. 182
Signs and diagnosis of chronic pe-
ricarditis 182
General signs 182
Physical signs 183
Sect. 111. Causes of Pericarditis .... 184
Sect. IV. Progress and Duration,
Terminations and Prognosis of
Pericarditis 187
Progress and duration 187
Terminations. 188
Prognosis 188
Sect. V. Treatment of Pericarditis . . 190
Treatment of acute pericarditis.. 190
Treatment of chronic pericarditis. 195
Sect. VI. Adhesion of the Pericar-
dium 196
Diagnosis of adhesion 198
CHAPTER II.
Carditis, or Inflammation of the
Muscular Substance 200
1. Universal carditis 200
2. Partial carditis, abscess, ulcer, rup-
ture of walls, valves, aorla, &c. 201
CHAPTER III.
Endocarditis, or Inflammation of
the Internal Membrane of the
Heart 203
Sect. I. Anatomical Characters of
acute Endocarditis. 206
A. Redness of the internal mem-
brane of the heart and arteries... 206
1. Non-inflammatory redness 206
2. Inflammatory redness 210
B. Effusion of lymph on the inter-
nal membrane, with thickening
of its substance 210
Concretions of blood from endocar-
ditis : 212
Sect. 11. Signs and Diagnosis of En-
docarditis 213
General signs 214
Physical signs 216
Sect. III. Causes, Progress and Du-
ration, Terminations, Prognosis,
and Treatment of Endocarditis . . 218
CONTENTS.
Xlll
Page
Causes, progress, duration, and ter-
minations 218
Prognosis, treatment 220
CHAPTER IV.
Acute and Chronic Arteritis, and
Organic Diseases of the Coats
of Arteries 221
Acute arteritis 221
Chronic arteritis 222
Morbid alterations in the coats of
arteries, and especially the aorta 222
Causes of morbid depositions in the
coats of arteries 225
PART III.
Organic Affections on the Heart
and Great Vessels 230
CHAPTER I.
Hypertrophy of the Heart 230
Sect. I. Anatomical Characters, wUh
Classification and Nomenclature
of Hypertrophy 230
Classification and Nomenclature.. 231
Natural dimensions and weight of
the heart 232
Anatomical characters of hypertro-
phy 240
Sect. 11. Mode of formation, with the
predisposing and exciting causes
of Hypertrophy 24-1
Mode of formation and predisposing
causes 244
Exciting causes -. 247
Sect. 111. Order of Succession in
which the serera! Compartments
of the Heart are rendered Hi/per-
trophovs by an obstacle before
them in the, coarse of the Circula-
tion 250
Comparative frequency of the forms
and combinations of hypertro-
phy * 253
Sect. IV. Pathological effects of Hy-
pertrophy 253
Effects of hypertrophy of the left
ventricle, and of organic diseases
of the heart in general, on the
brai n 25(5
Sect. V. Signs and Diagnosis of Hy-
pertrophy 203
General signs 203
J. Palpitation 263
2. Dyspnoea 204
3. Cough 204
4. Haemoptysis SJ65
5. Pulse 265
6. Affections of the head 206
Page
7. Complexion 206
8. Serous infiltration 267
9. Angina cordis 267
General signs of hypertrophy of
the right ventricle 268
General signs of hypertrophy of the
auricles 269
Physical signs. Impulse 269
Sounds 273
Dulness on percus-
sion 274
Prominence of the
precordial re-
gion 275
Sect. VI. Progress, Terminations,
and Prognosis of Hypertrophy . . 275
Progress and termination 275
Prognosis 278
Sect. VII. Treatment of Hypertrophy 278
Appendix to hypertrophy .. . 287
CHAPTER II.
Dilatation of the Heart 288
Sect. I. Anatomical characters with
Classification and Nomenclature
of Dilatation 288
Sect. II. Mode of formation, with pre-
disposing and exciting Causes of
Dilatation 293
Sect. III. Pathological effects of Dila-
tation and Mode of their Produc-
tion 295
Sect. IV. Signs and Diagnosis of
Dilatation 300
General si<nis 300
1. Serous infiltration 30L
2. Discoloration of the face 30L
3. Congestion of the brain 301
4. Injection of the mucous mem-
branes 301
5. Passive hemorrhage 301
6. Congestion and enlargement of the
liver 301
7. Angina of the heart. 302
General signs of dilatation of the
right ventricle 302
General signs of dilatation of the
auricles 303
Physical signs 303
Impulse 303
Sounds 304
Resonance on percussion 307
Physical signs of dilatation of the
auricles 308
Sect. V. Progress. Terminations, and
Prognosis of Dilatation 309
Sect. VI. Treatment of Dilatation.. 310
CHAPTER III.
Partial Dilatationor Real Aneu-
rism of the Heart 312
Abstract of Mr. Thui nam's paper . . . 313
XIV
CONTENTS.
;Page
Aneurism of the left ventricle 313
Aneurism of the auricles 321
CHAPTER IV.
Softening of the Heart 321
Anatomical characters of softening. . 321
1. Red softening 323
2. Whitish softening 324
3. Yellow softening 325
Signs and diagnosis of softening. . . . 326
General signs 326
Physical signs 327
Diagnosis 327
Prognosis 328
Treatment 329
Cases of softening 329
CHAPTER V.
Induration of the Heart 332
CHAPTER VI.
Adipose and Greasy Degenera-
tions of the Heart 333
Excess of fat 333
Greasy degeneration 334
Atrophy and oedema of the adipose
tissue 335
Cases of fatty heart, illustrating the
signs 335
CHAPTER VII.
Osseous, Cartilaginous, and other
accidental Productions con-
nected with the Muscular
Substance of the Heart, and
with the Pericardium 338
CHAPTER VIII.
Atrophy of the Heart 340
CHAPTER IX.
Diseases of the Valves and Ori-
fices of the Heart 341
Sect. I. Anatomical Characters, with
predisposing and exciting causes,
of Diseases of the Valves 341
Induration of the mitral valve.... 344
Induration of the aortic valves 347
Induration of the valves at the right
side of the heart 348
Predisposing causes of valvular dis-
ease 348
Exciting causes 348
Sect. II. Anatomical characters and
causes of Warty Vegetations of
the Valves 349
Sect. III. Pathological effects of Dis-
Page
ease of the Valves, and mode of
their Production 354
Sect. IV. Signs, Diagnosis, Progno-
sis, and Terminations of Disease
of the Valves 357
General signs of disease of the
valves 357
Pulse in valvular disease 358
in disease of the mitral valve 359
in contraction of the aortic
valves 361
in regurgitation through the
aortic valves 362
in valvular disease of the
right side 362
Pain in valvular disease 363
Progress, Terminations, and Prog-
nosis 363
Physical signs 364
Signs of disease of the aortic valves 365
of the pulmonic
valves 368
of the mitral valve 369
of the tricuspid
valve 372
of the arterial and
auricular valves conjointly 372
Diagnosis of valvular from inorga-
nic murmurs 372
Unusual and curious sources of
murmurs 375
Sect. V. Cardiac Asthma 376
General doctrine of asthma 376
1. Asthma from chronic dry catarrh. 377
2. Asthma from pituitary catarrh 377
3. Asthma from mucous catarrh 377
4. Asthma from disease of the heart. 378
5. Asthma from spasmodic constric-
tion of the bronchial tubes 378
Cardiac asthma described 379
Asthmatic fit described 381
Sect. VI. Treatment of Valvular Dis-
ease 384
Bloodletting 386
Diuretics 387
Purgatives 387
Diaphoretics 388
Emetics 389
Puncturing 389
Setons, Issues and Blisters 390
Expectorants 390
Gases 390
Antispasmodics 391
Stomachics 392
Tonics 393
Diet 393
CHAPTER X.
Aneurism of the Aorta 393
Sect. I. Classification, Nomenclature,
Anatomical Characters, and For-
mation of Aneurism of the Aorta. 394
Classification.. 394
CONTENTS.
XV
1. Dilatation or enlargement of the
whole circumference of the aorta
2. True aneurism, or lateral, partial,
dilatation of the aorta
3. False aneurism, or aneurism by ul-
ceration of the internal and mid-
dle coats
4. Mixed aneurism, or false aneurism
surmounting true
General observations on aneurism
of the aorta
Sect. II. Pathological Effects of Aneu-
rism of the Aorta on Contiguous
Parts
1. Compression of contiguous parts
2. Destruction of contiguous parts . .
Sect. III. Signs and Diagnosis of
Aneurism of the Aorta
General signs
Physical signs
Sounds
Purring tremor
Pulsation
Case of aneurism immediately be-
hind the heart
Strong and double jogging impulse
from this cause
Sect. IV. Synopsis of the Physical,
in conjunction with the General
Signs, in reference to the several
varieties of Aneurism of the Aurta
1. Simple dilatation of the arch, and
ascending aorta
Fallacies, and methods of detecting
them
2. Dilatation of the pulmonary artery
Diagnosis from dilatation and aneu-
rism of the aorta
3. Sacculated aneurism of the thora-
cic aorta
Fallacies, and methods of detect-
ing them
4. Sacculated aneurism of the abdo-
minal aorta
Fallacies, and methods of detect-
ing them
Case of aneurism of the abdominal
aorta
Anamic and nervous Pulsation of
the Abdominal Aorta
Its physical signs
Its general signs
Aortic Pulsation from Enteric In-
flammation
Appendix to Aneurism of the
Aorta
Case of aneurismal pouch of the
aorta bursting into the right ven-
tricle
Case of rupture of a dilated aorta
into the pulmonary artery
Signs of aneurism of the origin of
Page
394
39G
398
399
399
403
409
409
413
413
418
419
422
422
423
424
425
425
42G
427
427
428
430
432
434
435
436
43G
43G
437
437
439
Page
the aorta opening into the right
ventricle 440
Signs of aneurism of the aorta
opening into the pulmonary ar-
tery 441
Diagnosis of aneurism of the aorta
opening into the right ventricle,
or the pulmonary artery from
other diseases 441
Sect. V. Spontaneous Care and Medi-
cal Treatment of Aneurism of the
Anna, and Treatment of Xcrvous
Pulsation 442
Spontaneous cure 442
Medical treatment 443
Treatment of anaemic and nervous
pulsation 448
CHAPTER XI.
Malformations of the Heart.... 44 9
Communication between the two
sides of the heart .'•*;•• ^53
General signs of communication
between Che sides of the heart. . 455
Physical signs 457
Cases of communication between
the two sides of the heart 458
PART IV.
Nervous Affections of the
Heart 4GI
Spasms, Convulsions, and Paraly-
4G1
CHAPTER 1.
Xei ralgia of the Heart, or Angina
Pectoris 4GJ
Causes of angina pectoris 4G3
Nerves affected in angina 4G4
Diagnosis 4G5
Treatment 4G5
CHAPTER II.
Palpitation, particularly ner-
vous 4G7
Palpitation from inorganic causes,
usually called nervous, imitating
disease of the heart 4G8
1. From dyspepsia, hysteria, etc. ... 4G>
2. From anaemia 470
General symptoms of anamiia. . . . 470
Physical signs 471
Treatment of anamiia 472
3. From too stimulant diet 472
4 From plethora 473
Cases illustrative of palpitation. . 472
13— d
1 t hone
XVI
CONTENTS.
Page
Case 1. Dilatation with hypertro-
phy; overfeeding; simple apo-
plexy 473
Case 2. Dyspeptic and nervous pal-
pitation, with dilatation and cere-
bral congestion 474
Case 3. Dyspeptic, hypochondria-
cal, and nervous palpitation. . . . 475
Case 4. Plethoric dyspepsia, with
palpitation 476
Case 5. Plethoric congestion of the
heart, with palpitation and slight
dyspepsia 476
Case 6. Plethora; dyspepsia; hepa-
tic enlargement; jaundice; inter-
mission; palpitation; "fulness" of
the heart; and fainting 477
Case 7. Plethora; bilious engorge-
ment; intermission of the pulse;
occasional fainting; great oppres-
sion and debility 479
Case 8. Derangement of the sto-
mach, bowels, and liver; parox-
ysm of palpitation with orthop-
nea 480
CHAPTER III.
Syncope 480
Treatment 481
PART V.
Miscellaneous Affections 482
CHAPTER I.
Polypus of the Heart 482
Anatomical characters 483
1. Unorganized polypi 483
Page
2. Slightly organized polypi 483
3. More completely organized polypi 485
Causes and formation of polypous
concretions 485
1. From mechanical retardation of the
circulation 485
2. From inflammation 485
Signs and diagnosis of polypi.... 486
Physical signs 487
General signs 487
Treatment 488
Solubility of polypous concretions 490
CHAPTER II.
Displacements of the Heart 490
Symptoms 491
Diagnosis 491
CHAPTER III.
Hydropericardium 491
Signs and diagnosis 492
Treatment 492
CHAPTER IV.
Pneumopericardium 493
PART VI.
Cases 494
Description of the plates 545
Plates (Figs. 2 to 22, inclusive) . . 552
Plates 1 and 2 of dissecting aneu-
rism 552
Table of pulses of disease of the
heart 555
Appendix of the autopsies of
V . . . ., Esq., and Goft* 557
Index of cases 560
Alphabetical index 561
CONTENTS
OF
ADDITIONAL MATTER BY THE AMERICAN EDITOR.
Position of the heart Pa|l
The heart has no fixed relation "to the thorax .' .' .' ! .' .' .' \ ! .' .' .' .' .' .' .' .' .' .' .' .' .' \ \ \ .' '. .' .* 31
Kelative situation of the valves of the heart with the thoracic parietes 32
Experiments of Drs. Pennock and Moore 59
Auricular systolic sound C4. G7. 83. 90
T he second cardiac sound not diminished in simple hypertrophy 93
valvular extension insufficient for the production of the first sound 94
Congestion of the heart affects its sounds 63. 95
llie morbid conditions of the aorta sometimes prevent the formation of the
second sound 97
Cardiac sounds influenced by the state of 'the circulation.' W W W W W ! .' 98
l nickening of the aortic valves causes patescence and abnormal murmurs. ... 99
Kegurgitant murmur at the mitral valve heard near the left nipple 100
^gurgitation through the mitral valve arises sometimes from mental causes 103
■Tricuspid valve does not produce sound from regurgitation, unless diseased 105
Murmur at the tricuspid, where heard f.TT 104
Koughness of the aorta affects the heart's sound 106
Ambiguity of the terms used to express the cardiac sounds 110
Eesions causing different murmurs 112. 1 13
I he flexible stethoscope 117
Feeble pulse caused by regurgitation of blood 118
Dr. Williams's idea of murmurs 122
Cause of the utero-placental murmur 147
Case of utero-placental murmur caused by a tumor 153
Pericarditis may be local . 161
Louis on the lesions in pericarditis 162.163
Hypertrophy and dilatation in consequence of effusion in pericarditis 163
i- ain sometimes referred to epigastrium in pericarditis 165
Pericarditis often latent . . 166
Value of the sign of dulness on percussion in pericarditis 171
Outline of the space which is dull on percussion in pericarditis, is similar to
shape of the pericardium 172
Respiration absent over the praacordial space when much effusion exists in pe-
ricardium , 173
Friction sound of pericarditis .' .' .' .' .* .' .' .' .' .' .' .' .' .* .' .' .' .' .' .' .' .' .' .' .' .' .' .' .' .' .' .' .' .' . ... 175
nwn S°Und of Pericarditjs, double 177
L)r -Williams's idea of the "jogging motion " in pericarditis 179
M. Jjouillaud's views, respecting the connexion of articular rheumatism
with pen- and endo-carditis, adopted by the American auscultators 185
prognosis favourable in uncomplicated pericarditis 190
1 opical depletion in mild cases of pericarditis 195
Ur. Hallowell, on rupture of the heart 202
^violences of inflammation of the endocardium 212
tmoocarditis associated with acute rheumatism its signs 217
lo produce abnormal murmurs, greater lesions requisite at the aortic than at
the mitral valves . 219
Normal weight of the heart ...'.' " .* .* .* .' * * " ' " ! .* ' ' * .' " ' .WW *.*.'.'.' .' 233
M. Bizot's researches on the dimensions of the heart 234
Dimensions of the heart, in reference to age 235
XV111 CONTENTS.
Page
The heart increases in size in proportion to age 236
Dimensions of the heart, relatively to the height of the individual 236
breadth of the shoulders 237
■ capacity of the ventricles 237. 238
thickness of the left ventricle 238
to the thickness of the inter- ventri-
cular septum • • • • 239
Thickness of the walls of the right ventricle 239
Comparative thickness of the walls of the right and left ventricle in the two
sexes • • • • 239
Professor Andral's views of the size of the infantile heart, erroneous. . . . 240
The measure of the right ventricle which indicates hypertrophy 240
The character of the muscular tissue of the heart changed in hypertrophy.. . 240
Elongated hypertrophy of the heart 242
Hypertrophy and dilatation often arise from the same causes 247
Hypertrophy, not necessarily connected with valvular disease 250
Dilated hypertrophy of the right ventricle connected with contracted hyper-
trophy of the left 252
Pathological effects of hypertrophy upon the general system 262
Character of the dulness on percussion, variable as regards the space, and
situation 271
Impulse of the heart, influenced by the compartment affected 272
Respiration exists over the precordial region, even when that space may be
prominent 275
Treatment of hypertrophy 286
Measurement of the cardiac orifices 290
. by M. Bouillaud 290
—by M. Bizot 290. 291
Measurement of cardiac orifices acording to the age and sex 290
the right cardiac orifices 291
circumference of the aortic orifice 291
' pulmonary artery 291
Tissue of the heart changed in dilatation 295
Regurgitation through the right auriculo-ventricular orifice in dilatation. . . . 302
Articulate symbols for the sounds of the heart 307
Extent of dulness on percussion, and seat of impulse changed in hypertro-
phy, &c 308
Double pulsation accompanying dilated auricles 308
Apoplexy of the heart 313
Aneurism of the valves of the heart 321
Softening of the heart 328
Induration of the heart: Bertin and Bouillaud's views 332
Heart, overloaded with fat 333. 335
CEdema of the heart 335
Symptoms of abnormal cardiac productions 340
Obstructive and regurgitant lesions of the valves 351. 354
Disease of the valves of the left portion of the heart, most frequent 356
The period of the heart's action in which the morbid sounds are generated 365
Obstructive disease of the aortic orifice 366
Duration of murmur in the second sound 367
Combined obstructive and regurgitant lesions of the aortic orifice 367
General symptoms of disease of the aortic valves 368
Regurgitant lesions of the mitral valve * 370
General symptoms of disease of the mitral valve 372
Inorganic murmurs often heard over the apex of the heart 373
Dissecting aneurism 394
Cases of dissecting aneurism 402
Dulness of percussion along the margin of the sternum in aneurism of the
aorta . . ... 426
Dr. Worthington's case of cyanosis 451
Professor Dunglison's remarks on cyanosis.. .' 451
Case of angina pectoris 462
ITY
'ZC
INTRODUCTION
TO THE FIRST EDITION
Preceded by names so distinguished as those of Corvisart, Kreysig,
Barns, Laennec, and Bertin, I am sensible that I expose myself to
the imputation of presumption, in offering to the profession a new
treatise on the diseases of the heart and great vessels. I feel called
upon, therefore, to explain, in a more circumstantial manner than
I should otherwise have wished, the motives which have induced
me to undertake this work, and the plan which I have pursued in
its execution. Whether I am justified in the attempt 1 can scarcely
form an opinion. Every author contrives, I believe, to persuade
himself that the work which consumes his own midnight oil, is
precisely the one that is wanted. It is for the reader to determine
whether I labour under the delusion common to my brethren.
Notwithstanding the strong light diffused over the diseases of the
heart by the researches of the above mentioned authors, — notwith-
standing the brilliant sunshine emanating from the discovery of
auscultation by Laennec, — a discovery, which, according to M.
Bertin, " has, in a few years; more completely illumined the dia-
gnosis of the diseases in question, than all the other modes of explo-
ration had done for two centuries-/' the great body of the profession
still deny that the piercing ray has reached its destination, still
doubt the utility of auscultation in reference to the primary organ
of the circulation, still find the ordinary symptoms beset with their
accustomed difficulties, still complain, in short, that the obscurity
which involves the diseases of which we speak, is scarcely less
profound than ever;1 and, while conflicting opinions are embar-
1 A distinguished Frenchman recently said to me, " Monsieur, je ne crois
pas, pour vous dire la verite, que 1'on puisse en faire le diagnostic — que sur
la table du salon."
8— d 2 hope
18 HOPE ON DISEASES OF THE HEART.
rassing the judgment, and undermining the confidence of the patient
investigator of truth, there is a general outcry for an additional
mass of well-attested evidence, which may bring the subject to
some kind of a conclusion.
It rarely happens that a general impression is wholly unfounded:
nor is it, if I mistake not, in the present instance. Authors actually
have not succeeded in completely redeeming this subject from its
obscurity. Errors remained to be corrected, deficiencies to be sup-
plied, inconsistencies to be reconciled: the subject — a confused and
incongruous mass — required to be moulded and compacted into a
symmetrical and harmonious whole, the parts of which, while per-
fect in themselves, should, by their justness of proportion and unity
of design, afford relief and support to each other.
I proceed to glance briefly at the subjects where the principal
defects appear to have resided ; and this I do, not only for the pur-
pose of general guidance to the student, but also for that of pointing
out where I have differed from preceding writers.1 In these dif-
ferences, I am anxious to offer my opinions, not as established facts,
though I trust that they will be found grounded on careful obser-
vation, but simply as propositions to be admitted or rejected accord-
ing to the test of general experience. I am satisfied that, in our
profession more especially, where there are few fixed points to con-
stitute the basis of an inductive process, nothing is more difficult to
ascertain than a general fact. Innovations, therefore, cannot be
regarded with too much suspicion, cannot be scrutinised with too
much severity, cannot be received with too much caution and
reserve."
The most prominent error which reigns throughout the doctrines
of Laennec, and which has prevailed in the schools since the first
publication of his work, is, that he mistook the nature of the action
of the heart. I trust that the view which I have ventured to sub-
stitute may be found more satisfactory; and, as nearly a year and
a half has elapsed since I first published my experiments and cli-
nical observations relative to it : as my conclusions have, through-
out that period, remained, so far as I can judge, uninvalidated ; and
as I have recently repeated the experiments with the same results,
before a number of the most distinguished physiologists and patho-
logists of the metropolis ; 3 I hope I shall not be considered preci-
pitate in having taken the decisive step of modifying and explaining
all the physical signs of disease of the heart according to the view
in question.
Laennec and his predecessors have assigned to diseases of the
heart a certain series of symptoms, which they conceived to be
1 The further defects, which have been supplied in the present edition,
arc briefly enumerated in the preface.
2 Vid. p. 36, 38 and 44. To these may now be added, my experiments
on the sounds in 1835, detailed at p. 48 et seq.
INTRODUCTION. 19
common to the whole; but they had not analysed those symptoms,
and ascertained which were peculiar to, and pathognomic of, the
several affections taken individually. MM. Bertin and Bouillaud,
both writers of high talent, made this attempt, and with partial
success ; but the spirit of generalisation (if I am correct in my own
views) carried them a grade too far. What observation leads me
to regard as an inaccuracy, constitutes the hinge of their work —
the pivot on which turns the principal train of their reasoning :
namely, that the symptoms of a retarded circulation are, under all
circumstances, the result of a mechanical obstacle to the course of
the blood : — that when, for instance, they accompany hypertrophy
or dilatation, they are not consequences of these affections, but of
some co-existent mechanical obstacle, as a contracted valve, an
aortic aneurism, &c. I have attempted to show, not only that hy-
pertrophy, dilatation, and softening can, of themselves, respectively
occasion the symptoms in question ; but, that these symptoms are
seldom produced in any very remarkable degree of severity by a
mechanical obstacle, unless hypertrophy, dilatation, or softening of
the heart is superadded. x
It may naturally be supposed that the erroneous view which
Laennec took of the heart's action, led to corresponding errors in
his doctrines of auscultation. The errors are principally those of
omission and of incorrect explanation. The omissions are consi-
derable and important. He was not aware of a fact first noticed by
the writer in June 1825, namely, that murmurs are produced by
regurgitation through the valves. This oversight alone naturally
shook the confidence of many, and eventually of himself, in his
theory of valvular murmurs. For, the lesion being found in one
valve, when, according to that theory, it was expected in another,
the inevitable conclusion was, that the theory was incorrect. At
the same time, the cause of the murmur remained doubtful.
The perplexity was further increased by the existence of mur-
murs independent of valvular disease, and accompanying anaemic
and nervous palpitation without any organic lesion whatever.
These murmurs Laennec attributed to a wrong cause: viz. to the
sound of the muscular contraction, instead of to the modified mo-
tion of the fluid ; which I presume to consider the true cause.
Hence, he was unable to analyse and foresee the circumstances
under which nervous and anaemic murmurs should occur, and,
1 M. Bouillaud complains that I have misrepresented his opinions in the
above paragraph. With the utmost anxiety to correct my mistake and make
ample amends, I have thoroughly and carefully examined his work in 1824
and that in. 1835, and I am sorry to say that I cannot detect any just
foundation tor his complaint. I have shown in section iii. i?ifra, by quotations
and references, that he really entertained the opinions which I have ascribed
to him, and that he still maintains the same in his later work.
2*
20 HOPE ON DISEASES OF THE HEART.
consequently, to distinguish them from those occasioned by valvular
disease.
Several minor phenomena likewise, as the purring tremor, and
the arterial thrill and bellows-murmur, he was, in consequence of
the confusion created by the error in question, equally unable to
explain. Hence, he vaguely attributed them to some unknown
" modification of the nervous action."
It cannot be a subject of surprise that, with the above opinions,
acquired chiefly during the latter period of his life, he should have
retracted, in his second edition, the much more accurate doctrines
respecting murmurs as signs of valvular disease, which he had
advanced in his first; — transmitting to his disciples the confusion
which reigned in his own mind, but which, like the storm that, in
tropic climes, is the precursor of the purest, brightest weather, must,
sooner or later, had his life been spared, have rolled away before
the irresistible force of his purifying and enlightening genius.
The murmurs attending valvular disease, nervous palpitation,
reaction from loss of blood, and anaemic or chlorotic palpitation in
general ; also the allied phenomena of purring tremor, and arterial
thrill, throb, and murmur,1 I have attributed to modifications in
the motion of the blood, and explained according to the laws of
hydraulics and acoustics. In this way, not only may organic dis-
eases of the heart be readily and certainly distinguished from ner-
vous and other affections wearing their aspect, but, with attention
to certain rules which I have offered respecting the situations
where valvular sounds are to be explored, and to certain corrobora-
tions derived from general symptoms, the particular valve diseased
may in general be detected with precision. Such, at least, are the
conclusions to which I have been brought by a very considerable
number of cases, a small proportion of which are appended to this
volume.2
1 To these, the venous murmur has been added in the present edition.
2 I am enabled in the present edition to speak much more decidedly even
than in the above paragraph, having constructed a code of rules of so sim-
ple a nature that the particular valve presenting a murmur, whether from
constriction or regurgitation, may be detected with demonstrative certainty
in every instance where the murmur is distinct. In Aug. 1828, I tested
these rules on four intelligent students of St. George's Hospital, professing
to be total strangers to the auscultation of the heart. After employing ten
minutes in giving them verbally the explanation appended to the diagrams
Fig. 4. A, 4. B, 4. C, I introduced to them six patients presenting five dis-
tinct varieties of valvular disease, including the pulmonic. They delivered
in writing sixteen diagnoses, of which fourteen w^re perfectly correct, and
two only were partially defective (see Med. Gaz. Sept. 1828). I have sub-
sequently seen numerous students and various practitioners become practi-
cal adepts in the course of a few weeks, by committing the rules and dia-
grams to memory and examining fifteen or twenty cases, which I constantly
keep accessible in my hospital practice. As an instance of the ease with
INTRODUCTION. 21
The investigations of Laennee on aneurism of the aorta, were
limited and inconclusive: accordingly, he remarks that, "of all the
severe lesions of the thoracic organs, three alone remain without
pathognomonic signs to a practitioner expert in auscultation and
percussion, — namely, aneurism of the aorta, pericarditis, and polypi
in the heart previous to death." I hope that my attempts to throw
light on these subjects, may not be found entirely fruitless. The
article on aneurism is the substance, with considerable additions,
of a series of essays published in the Lond. Med. Gaz. Aug. 22,
1829, and is founded on nearly forty cases in which the diagnosis
was verified by post mortem examination. It was originally the
subject of the writer's inaugural dissertation.
The treatment of diseases of the heart offers a spacious field for
improvement. Previous to the discovery of auscultation, these
maladies could seldom be detected before they were so far advanced
as to be incurable; and then was not the time to judge of the
efficacy of remedies. Laennee, absorbed in his investigation of the
diagnosis, paid comparatively little attention to the treatment. His
first edition scarcely alluded to it: in the second it is only curso-
rily treated. Bertin and Bouillaud are not more satisfactory, —
giving a bold outline of leading principles, such as might be struck
out by generalisation in the closet, but seldom descending into those
datailed delineations of therapeutic measures, which are essential
to the practitioner at the bedside.
Nor are these principles always, perhaps, perfectly sound. Their
habit of attributing the symptoms of a retarded circulation, under
all circumstances, to one cause only, — a mechanical obstacle, gives
a wrong bias to the mind ; and that of entwining inflammation
with the cause of almost every organic lesion of the heart or great
vessels, is replete with danger to the inexperienced practitioner.
While I feel bound to say this, (for it is the duty of a writer to
point out the path which is insecure, no less than that which is
safe,) let me not be supposed to detract from the singular merits of
these authors: let me offer my tribute of admiration to the talent
which shines through every page of their elegant and scientific
work, and acknowledge the extensive obligations that I owe it in
the execution of my own.1
which a student will unravel the most complex case, the reader is referred
to the case of GofF.
The utility of particular valvular diagnosis is explained hereafter, in chap,
ix. sect, iv., in treating of the diseases of the valves.
1 M. Bouillaud has dwelt little more on the treatment in his Treatise in
1835, than in his previous work. For instance, he dismisses so important a
subject as hypertrophy in two pages, and to dilatation he gives three lines!
His treatment of the worst cases of hypertrophy by the profuse bleeding
system of Albertini and Valsalva, is not only strongly objectionable for the
reasons specified, chap. i. sect, vii., but is singularly inconsistent in a writer who
has insisted so strenuously on palpitation being produced by anaemia! My
22 HOPE ON DISEASES OF THE HEART.
Coqscious of the gap that was presented in the treatment of dis-
eases of the heart, I have devoted more attention to this than to
any other department of the subject: availing myself, in particular,
of the wide and favourable sphere for observation, afforded by a
long residence as House Physician and Surgeon successively, in
the Royal Infirmary of Edinburgh ; where living, literally, I may
say, as well as figuratively, at the bedside of the patient, I had an
opportunity of closely watching every habitude and phasis of the
disease — every operation and effect of remedies. The results of
these researches were submitted in a memoir to the Royal Medical
Society of Edinburgh, in the year 1824-5.
Many think that the expectation of effecting an improvement in
the treatment of diseases of the heart, is chimerical: and they think
so because, not being accustomed to recognise the diseases in ques-
tion before they have attained an advanced stage, they are pre-
occupied with the old and popular idea of their incurability. To
such it might, perhaps, be a sufficiently philosophical answer to
reply, that an improved knowledge of the nature and causes of a
disease must alone necessarily lead to an improvement in the treat-
ment; and that therapeutic weapons are dangerous when wielded
in the dark. But here we may go much farther : we may say that,
by the improved means of diagnosis, the maladies under considera-
tion may be recognised, not only in their advanced but in their
incipient stages, and even when so slight as to constitute little more
than a tendency. We may say, on the grounds of incontestable
experience, that, in their early stages, they are, in a large propor-
tion of instances, susceptible of a perfect cure ; and that, when not,
they may, in general, be so far counteracted as not materially, and
sometimes not at all, to curtail the existence of the patient. We
may, accordingly, predict that, the term "disease of the heart,"
which at present sounds like a death knell when uttered by the phy-
sician, will hereafter become by familiarity not more alarming than
the term asthma, under which it is frequently disguised.
Such are the direct practical improvements to be expected from
a better knowledge of diseases of the heart. But there are col-
lateral ones of no less magnitude. It has been stated by M. Rich-
erand, repeated by Bertin, and echoed by all who are conversant
with this class of maladies, that " hypertrophic enlargement of the
heart is more closely allied to apoplexy and palsy than the apo-
plectic constitution itself." l
Should the hypertrophy be recognised, its effects on the brain
equally strong objections to his extravagant, dangerous, and, after all, inef-
ficient and unnecessary bleedings for acute rheumatism and rheumatic
inflammation of the heart, are unfolded in chap. i. sect. iv. and vi. on Peri-
carditis.
1 This constitution consists, according to the popular idea, in a broad,
robust frame, full habit, and florid complexion. It is in general attended
with an unusual size and thickness of the heart.
INTRODUCTION. 23
may be counteracted by judicious treatment: should it be over-
looked, the patient, with a view to reducing his apoplectic fulness
of habit, is ordered smart exercise, which, by increasing the action
of the heart, already too powerful, causes a preternatural determi-
nation of blood to the brain, and induces the apoplectic or paralytic
seizure. According to evidence hereafter to be adduced, the ma-
jority of those who are prematurely cut off by apoplexy in the
apparent enjoyment of good health, sink under the circumstances
described. ■
Again, there are few more common and certain exciting causes
of palpitation and difficulty of breathing in disease of the heart, than
derangement of the stomach. What happens to the patient in this
case? Tracing the attack, in perhaps every instance, to a dyspeptic
fit, he naturally concludes that the latter is the cause : that it is ': all
indigestion.'*' "Good air, and plenty of exercise,"' are the remedies
recommended: the result is an apoplectic seizure. The circum-
stance that before the introduction of the new mode of exploring
diseases of the heart, they could rarely be detected in their early
stages, contributed to the error in question. For, as patients fre-
quently recover from the early stages, the recovery was regarded,
by those who assumed this class of diseases to be incurable, as a
proof that the affection was merely dyspeptic. Hence dyspepsia
acquired the reputation of producing certain symptoms, particu-
larly in the head, which are in reality foreign to it, being exclu-
sively the results of a co-existent disease of the heart.
There prevails another error, the converse of the above — that of
mistaking anaemic, nervous, dyspeptic, and other varieties of pal-
pitation, for disease of the heart. The frequency of cases of this
kind, especially amongst men of studious habits, (and more parti-
cularly, I have noticed, among those of my own profession,) is truly
surprising: and as it has always been considered difficult, and by
many impossible, to distinguish the two affections, the alarm created
is sometimes distressing. Having thought this subject of so much
importance as to demand a separate article, (see Palpitation,) I
shall here only say, that, so far as my own experience enables me
to judge, the discrimination may be made with ease and certainty.
An immense proportion of asthmas — and of the most dangerous
and distressing cases, result from disease of the heart: the same
may be said of dropsies, especially those that are universal. If the
cause be overlooked, the asthmatic is harassed with a farrago of
inappropriate and unavailing, not to say pernicious, remedies ; and
the hydropic is treated with dangerous activity, or for imaginary
affections of the liver, the lungs, or the kidneys. On the other
hand, if the cause be detected in the incipient stage, by precau-
1 It is shown in the present edition, chap. i. sect, iv., that other diseases
of the heart, besides hypertrophy, are causes of apoplexy.
24 HOPE ON DISEASES OF THE HEART.
tionary measures both the one effect and the other may in general
be prevented.
In acute rheumatism, there is no more common and formidable
source of danger than inflammation of the heart and its investing
membranes. Should it be overlooked when existing in a severe
form, (and even in that form it is, to those unacquainted with aus-
cultation, one of the most obscure and insidious of maladies,) the
patient almost invariably dies from the immediate effects of the
attack, or becomes a short-lived martyr to an incurable organic
disease of the heart.
There is scarcely a disease of the heart, accompanied with ob-
struction of the circulation for any considerable period, which is
not productive of enlargement of the liver, and, sooner or later, of
its ordinary consequence, abdominal dropsy. Yet there are few
common facts in medical science less generally known than this
intimate connection between the heart and the liver. The dropsy
is ascribed to the latter ; the treatment extends not beyond this
organ ; the unknown cause continues to reproduce its effect, and
the patient, if he obtain relief at all, only obtains it to undergo a
speedy relapse. 1
Individuals affected with disease of the heart are peculiarly liable
to inflammation of the lungs; and such inflammation, as I have
endeavoured strongly to inculcate throughout this volume, is sin-
gularly rapid and destructive. Yet if, from ignorance of the state
of the heart, free depletion be practised on the ordinary principles,
the patient may sink suddenly after the first or second abstraction
of blood. I have more than once witnessed this catastrophe, and
few practitioners of experience have not seen the same.
In fever and inflammation in general, disease of the heart may
impart to the pulse dangerously deceptive characters of hardness,
fulness, weakness, or irregularity, and the patient may be bled too
much, from the prevalence of the former characters, or too little,
from the presence of the latter. 2
Thus it is seen that the practical improvements to be derived
1 Similar remarks often apply to enlargement of the spleen, to hemor-
rhage from the stomach connected with congestion either of the liver or the
spleen, to bleeding piles dependent on engorgement of the portal system,
and occasionally even to uterine hemorrhage.
[The triple lesion of organic change of the heart, liver, and kidneys, is
presented in a majority of the cases of diseases of the central organ of the
circulation. — P.]
2 I have offered, at the termination of the work, a complete table of the
pulses of disease of the heart— the first, I believe, that has ever been at-
tempted. They imitate all the pulses of ordinary disease : consequently,
unless the practitioner can make allowance for disease of the heart, the
pulse is a fallacious criterion of other affections. This appears 10 me to be
the main reason why there has been, from time immemorial, so much dis-
agreement amongst authors respecting the indications of the pulse and its
value as a sign of disease.
INTRODUCTION. 25
from a better knowledge of the diseases of the heart; extend, not
to the diseases of this organ alone, but to a multitude of the most
formidable maladies incident to the human frame. There is, in
short, scarcely an affection with which disease of the heart may not
be more or less interwoven ; and "if," to use the language of Senac,
"we would not pronounce rashly on an infinity of cases; if we
would not harass our patients by noxious and unavailing reme-
dies ; if we would not accelerate death by treating certain diseases
like others which are entirely different; nor be exposed to the dis-
grace of seeing our diagnosis falsified by the results of dissection;
finally, if we would not have danger to be imminent, whilst we are
under the blind impression that it is remote, we must study the
diseases of the heart."
Such appear to be the vacuities left by preceding writers, and
such the advantages to be anticipated from their being supplied.
It remains for me to explain the plan of the present work, and
glance at a few particulars in its execution.
The work is divided into six parts ; I. The Anatomy and Phy-
siology. II. Inflammatory affections. III. Organic affections.
IV. Nervous affections. V. Miscellaneous affections. VI. Cases.
Although every arrangement of diseases of the heart presents con-
siderable difficulties, and I am by no means perfectly satisfied with
the one which I have adopted, it appears to me preferable to others,
because affections of the same class, being thrown together, by jux-
taposition reflect light upon each other; nor, at the same time, are
the inflammatory and the organic affections in general so intimately
connected, as to render their separation impossible without doing
violence to the continuity of the subject. The miscellaneous affec-
tions are ranged by themselves, because they are not reducible to
any of the preceding heads.
In the execution of the work, it has constantly been my aim, by
studying the symptoms in connection with the morbid anatomy, to
trace the alliance of the two as cause and effect, and thus to
reduce them to certain general and intelligible principles, which
might not only contribute to future accuracy of observation, but
facilitate the registration of so many and so complicated facts in the
memory.
As the authenticity of cases and observations is of the first im-
portance, I deem it necessary to present a short explanation of the
manner in which I have conducted my investigations. Being
persuaded that no evidence is so suspicious as that of the senses,
because the magnitude of an error is in proportion to the certitude
which is supposed to attach to that mode of exploration, it has con-
stantly been my endeavour to avail myself of the collective testi-
mony of many. Accordingly, I have, for publication, preferred
hospital cases, as being the best attested ; I have invariably written
the opinions or diagnoses before the death of the patient; have
publicly tested them by the results of post mortem examination ;
26 HOPE ON DISEASES OF THE HEART.
have minuted the dissections with the subject before me, and ac-
cording to the prevailing opinions of the individuals present; and,
generally before laying down my journal, I have annexed such
remark as the case suggested, while the circumstances were fresh
in my recollection. Finally, I have obtained signatures where a
case was very remarkable, or where there appeared a possibility of
its being subsequently called in question. The cases appended to
this work are nearly verbatim transcripts from journals thus kept;1
and, in order that they might present a just idea of the possibility
of detecting disease of the heart, I have not taken them by selection,
but, excepting a few, mostly without diagnoses, have introduced
the whole of which I took notes in St. George's Hospital within a
definite period. They will be found, I believe, to substantiate the
view which I have offered of the heart's action—according to which
the physical signs are explained ; and, to the practical student of
auscultation, by standing in the relation of exercises to a grammar,
I entertain hopes that they may prove one of the most acceptable
portions of the volume.
The hospital researches alluded to have been conducted at the
Royal Infirmary of Edinburgh, as above stated : at St. Bartholo-
mew's, London : at La Charite, Paris, where the lessons and re-
searches of MM. Chomel,2 Andral, and Louis afforded the most
favourable opportunities for auscultation : at the Santo Spirito,
Rome: and, finally, at the Marylebone Infirmary and St. George's
Hospital, London. From these and private sources I have minuted
a greater number of cases than has, I believe, been published by
any previous author.
In some parts, I have occasionally introduced repetitions. Thus,
in describing the mode in which changes of structure produce their
pathological effects, I have glanced at the symptoms ; and in de-
scribing the symptoms, I have explained them, where practicable,
by the changes of structure. This I have done designedly; for I
am satisfied that such is the process of thought which passes
through the mind at the bedside and in the post mortem theatre;
and a practical work ought to be the transcript of the mind in those
two situations. I have, likewise, made occasional repetitions in
the treatment with the view of saving the reader the inconvenience
of frequent reference.
Wherever the subject was one of original research, or otherwise
1 Except the cases added to the present edition and dated subsequent to
1831.
2 I owe it to the politeness of the French nation in general, and of this
gentleman in particular, to state, that he not only granted me the privilege
of being one of his clinical assistants; but, as I was engaged in making
drawings of morbid structure, he also allowed me the immediate use of the
best specimens which his wards afforded, purposely postponing the demon-
stration of them to his class till the following morning.
INTRODUCTION. 27
particularly important, I have been circumstantial. Aneurism of
the aorta, hypertrophy, the signs of disease of the valves, &c. may
be cited as instances.1 Where the subject was known, I have pre-
sented those points only, of which I am myself conscious of making
use in practice, suppressing many subordinate minutiae, which,
though essential to original researches, gradually become super-
fluous, in proportion as the alchemic process of generalisation
assays, and assigns their full value to leading facts. Accordingly,
I must refer the reader to Laennec for many details, which evince
the astonishing accuracy and extent of his first researches, but
which are no longer requisite for practical purposes. On the sub-
ject of the morbid anatomy of the heart I have been minute, — per-
haps tediously so; but it has appeared to me necessary, because
there is perhaps no organ in the body, of the diseased states of
which the generality are less competent judges than of the heart;
and this is the source of the frequent and dangerous error of con-
founding organic with nervous disease, or of overlooking the for-
mer entirely.
I am prepared to expect some dissent from my views respecting
asthma as symptomatic of disease of the heart. Being the results
of observation, I submit them with confidence, but shall be the first
to recant, should they be demonstrated to be erroneous. I learn
that M. Rostan entertains similar views, but having completed my
manuscript, and thinking nature a sufficient guide. I have refrained
from consulting his works.
With respect to the comparative value of the general and phy-
sical signs of disease of the heart, it may be said that Laennec
rather undervalued the former and over-rated the latter. This
was owino; principally to the general signs beinof less perfectly
understood when he studied than they have subsequently become
in consequence of being investigated with the aid of auscultation.
The ardour of his early disciples, who imagined that the physical
rendered the general signs superfluous, brought auscultation into
some disrepute by the inaccuracy of their diagnosis. But since
the stethoscope has taken its proper place as an auxiliary only,
and the diagnosis has been founded on the two classes of signs
conjointly, auscultation has ranked as a discovery which will
immortalise its author and form an epoch in the history of medi-
cine.
[Previous to the brilliant researches of Dr. Hope on the heart's action, in
1832, the pathology of the central organ of the circulation was most singu-
larly involved in doubt. Pathologists, with but few exceptions, did not hesi-
tate to acknowledge their inability to render a positive diagnosis in the
cardiac affection, and, if luckily their notions of the patient's disease should
be verified by examination after death, it was regarded as a happy circum-
stance, rather than as indicating any positive knowledge on the subject. But
a new era in medicine commenced when Hope promulgated to the medical
1 Also the sounds of the heart.
28 HOPE ON DISEASES OF THE HEART.
world, his celebrated experiments, which tended so signally to dispel the
erroneous views previously entertained. Since that period, this branch of
the science has been cultivated with great ardour, and it was soon found,
that, although the ideas of our author respecting the physiology of the heart's
action were mainly correct, yet, important facts remained to be elucidated.
Zealously co-operating with others, he was enabled to correct his first im-
pressions, and the result has been the production of a work, which will
endear his memory to the medical profession, and place his name high in
the list of benefactors of mankind.
This edition, the first presented to the American public, is from the third
of the London press, and contains the author's latest views. It is to be re-
gretted that some parts have a controversial character, and the American
editor, when he first read them, was disposed to suppress them; but further
reflection has induced him to offer the entire text as left by the distinguished
author. Notes have been presented in this edition, the result of the editor's
personal observation, and the occasional introduction of views of writers,
who, though deeply versed in the pathology of the heart, have not arrived at
precisely the same conclusions with those of the author: amongst these, the
talented Dr. C. J. B. Williams claims a prominent place.
The experiments on the heart's action by American observers, and the
most recent result of the British investigations, have been introduced after
those of the author.— P.]
PART I.
ANATOMY AND PHYSIOLOGY
OF THE HEART.
CHAPTER I.
ANATOMY OF THE HEART.
As morbid anatomy and pathology are only comparative states,
or the amount of a deviation from the healthy standards of anatomy
and physiology, it is essential for these standards to be thoroughly
understood, before the morbid deviations can be appreciated. Of
the descriptive anatomy of the heart it is not, however, my inten-
tion to treat, as this subject presents no obscurity, and as it ought
to be studied in much greater detail than is consistent with the
plan of the present work. I pretermit, likewise, that portion of the
physiology which relates to the arrangement and action of the
muscular fibres, referring the reader to Stenon, Wolff, Duncan,
Gerdy, and other original sources of information! It may be briefly
observed, that some imagine the systole to be effected by the con-
traction of a certain set of fibres, and the diastole by that of another;
that, in short, the latter, as well as the former, is the result of an
active muscular effort. This, however, has not yet been satisfac-
torily demonstrated ; and, while awaiting the issue of further re-
search, it is perhaps safer, for the present, to attribute the diastole
to that power by whicli a muscle reverts from the state of contrac-
tion to that of relaxation, and which I shall, for the sake of avoid-
ing circumlocution, designate by the title of elasticity.
There is one point, which is generally treated in too cursory a
manner by descriptive anatomists, and the thorough knowledge of
which is absolutely essential to the study of diseases of the heart.
I allude to the relative size of the organ to the whole frame, and of
its several compartments to each other. It is ignorance in this re-
spect that has for centuries caused thickening, attenuation, enlarge-
ment, and diminution to be overlooked, and the symptoms of disease
30 HOPE ON DISEASES OF THE HEART.
of the heart to be attributed to any cause but the legitimate one. As
the subject might escape notice if introduced in this place, I have
treated' of it immediately before describing the anatomical characters
of hypertrophy, where it will be both conspicuous and convenient.
The weights and measurements of M. Bouillaud are also added.
A knowledge of the exact situation of the heart is a point of no
less importance to the auscultator ; and, though it does not strictly
come under the head of anatomy, I shall, for convenience, advert
to it here. The drawing opposite to the title-page illustrates the
following description.
As the apex and body of the heart are free, while the base,
secured by the great vessels, is comparatively, though not abso-
lutely, fixed, the organ turns in a slight degree upon its base with
each alternate movement of the diaphragm, the descent of the mus-
cle causing its longitudinal axis to assume a more vertical position,
and the ascent throwing it transversely to the left. It is necessary,
therefore, that the auscultator fix upon some given point at the
base, which may serve as a mark and guide for his exploration of
the situation of the organ. The point which to myself has appear-
ed the most certain, is the pulmonary artery. This vessel, near
the place where it divaricates into the two trunks distributed to the
lungs, bulges, while the subject is horizontal, at the interspace be-
tween the second and third left ribs close to the sternum — a circum-
stance which, as well as the situation of the other parts of the heart,
I have carefully ascertained by forcing needles through the thoracic
walls, at given points, into the viscera beneath. The situation of
the pulmonary artery was also well displayed by the dilatation of
that vessel described in the case of Weatherly. At the spot alluded
to, namely, between the second and third left ribs, close to the
sternum, the second sound of the heart is louder even than oppo-
site to the pulmonic valves themselves. This is simply because
the sternum is not interposed; for the sound attains its maximum
of intensity when the subject lies inclined to his left side, by which
the pulmonary artery is forced as far as possible beyond the outline
of the sternum ; and, on the contrary, when he lies inclined to-
wards his right side, by which the vessel is drawn under the ster-
num, the sound is no longer peculiarly audible between the second
and third ribs. I have derived a further confirmation of the same
fact from observations made on a patient shown to me by Mr. Mayo.
and subsequently on three others, in whom pleuritic effusion in the
left cavity of the chest had protruded the heart to the right side of
the sternum (see Displacements). Here the sound of the aortic
valves was as loud between the second and third ribs on the right
side, as that of the pulmonic valves naturally is in the correspond-
ing situation on the left. When the patient is in the erect position,
the gravitation of the heart straightens. and pulls down the pulmo-
nary artery, so that the sound is less audible in the second costal
interspace.
A line drawn from the inferior margins of the third ribs across
ANATOMY OF THE HEART. 31
the sternum, passes over the pulmonic valves a little to the left of
the mesial line, and those of the aorta are behind them, but about
half an inch lower down. From this point the aorta and pulmo-
nary artery ascend ; the former inclining slightly to the right,
coming in contact with the sternum when it emerges from beneath
the pulmonary artery, and following, or perhaps rather exceeding,
the mesial line, till it forms its arch; the pulmonary artery, which
is, from the first, in contact with the sternum, inclining more con-
siderably to the left, until it arrives at the interspace between the
second and third ribs above described. A vertical line, coinciding
with the left margin of the sternum, has about one third of the
heart, consisting of the upper portion of the right ventricle, on its
right; and two thirds, composed of the lower portion of the right
ventricle and the whole of the left, on its left. The apex beats be-
tween the cartilages of the fifth and sixth left ribs, at a point about
two inches below the nipple, and one inch on its sternal side.
The lungs descend along the margins of the sternum about two
inches apart, and overlap the base of the heart, slightly on the right
side, and more extensively on the left: then, receding from each
other, they leave a considerable portion of the right ventricle, and
a less extent of the lower part of the left, in immediate contact with
the thoracic walls.
The right auricle is in front of the heart, at its right side and
upper part. One portion of it is overlapped by the right lung, and
another, principally the appendix, is in contact with the sternum.
The left auricle is situated deeply behind and to the left of the
heart at its upper part, opposite to the interval between the carti-
lages of the third and fourth ribs. The extremity of the appendix
is visible in front, but, when the volume of the heart is natural, it
is not in contact with the sternum, being considerably overlapped
by the left lung. The auricular orifices are situated opposite to the
interspace between the third and fourth ribs, and the right is rather
lower down than the left. As, however, the orifices are overlapped
by the lungs, the sound of their valves is much less audible imme-
diately over them than near the apex of the heart, to which part
the sound is conducted by the chorda) tendinea) and columnar car-
nea3. The pericardium ascends on the great vessels as high as the
commencement of the arch of the aorta, and opposite to the second
ribs.
[When the heart of a living animal is exposed, it is seen that its only
fixed and stationary point is at the valves of the aorta ; the other large blood-
vessels at the base revolve partially around this point, and the body of the
heart being free, no fixed relation exists between it and the walls of the tho-
rax; but it hangs, in a certain degree, loose, and liable to displacement by
changes of posture and by the motions of the chest. It is of the first im-
portance, therefore, that the pathologist should be correctly informed as to
the precise situation of the semilunar valves of the aorta. Repeated obser-
vations made on the dead body have proved, that these valves are pierced,
if needles be introduced perpendicular to the plane of the sternum through
the middle of that bone opposite the middle of the cartilages of the third ribs ;
32 HOPE ON DISEASES OF THE HEART.
and that, if the wires be passed perpendicular to the tangent of the curved
surface of the thorax, between the cartilages of the second and third ribs,
half an inch from the left margin of the sternum, the semilunar valves of the
pulmonary artery are entered. The aorta, from its origin, curves upwards
towards the right, extending between the cartilages of the second and third
ribs slightly beyond the right margin of the sternum; at the lower margin of
the cartilage of the second right rib, the arch of the aorta commences and
inclines to the left, crossing the pulmonary artery where it lies beneath the
cartilage of the left second rib, and ascending as high as the first rib, turns
downwards. The pulmonary artery, from its origin in contact with the
sternum, commences at the left margin of that bone, where it is joined by the
cartilage of the third rib, bulges at the interspace between the second and
third cartilages close to the sternum, and dips beneath the aorta opposite the
junction of the second cartilage and sternum.
The right divisions of the heart, being most superficial, form the greater
pait of the anterior surface; the right auricle reaches from the cartilages of
the third right rib to that of the sixth; and between the third and fourth,
where its extent is the greatest, it extends, laterally, when filled with blood,
near one inch and one third to the right of the sternum. About one third of
the right ventricle lies beneath the sternum, the remaining two thirds being
to the left of that bone ; the septum between the ventricles coincides with the
osseous extremities of the third, fourth and fifth ribs, and on the fourth rib is
midway between the left margin of the sternum and nipple. A small part,
say one fourth, of the left ventricle, presents anteriorly, and when the lungs
are separated, a portion of the left auricle is visible between the second and
third left ribs two inches from the left margin of the sternum. With the
exception of these portions, the whole of the left ventricle and auricle lie
posteriorly to the right ventricle; and the entire left divisions, with the ex-
ception of a small portion of the base connected with the pulmonary valves
of the aorta, lie on the left of the sternum.
In the dead body, the normal situation of the tricuspid valve extends ob-
liquely downwards from a point in the middle of the sternum immediately
below the third rib, to the right edge of the sternum where that bone is connect-
ed with the lower margin of the cartilage of the fifth rib; the mitral valve
commences beneath the lower margin of the left third rib, near the junction of
its cartilage with its osseous extremity, (two and a half to three inches to the
left of the sternum,) and runs slightly downwards, terminating opposite the
left edge of the sternum, where it is joined by the upper margin of the carti-
lage of the fourth rib. — P.]
When the heart is enlarged, its longitudinal axis becomes placed
more transversely, and its lateral diameter is increased. Hence,
the right ventricle projects more considerably to the right, some-
times under the whole breadth of the sternum ; and the left extends
far beyond its usual limits to the left, sometimes elevating by com-
pression that portion of the lung which overlaps it; so as to bring
nearly its whole surface, and the tip of the auricular appendix, into
contact with the walls of the chest. In addition to being broader
and placed more transversely, the organ descends lower than natu-
ral— its apex sometimes beating between the sixth and seventh ribs,
and its pulsation extending to the epigastrium.
When the right auricle is dilated or gorged, it extends upwards
and to the right, and comes more extensively in contact with the
sternum.
When the pericardium is distended to the utmost with fluid, it
ANATOMY OF THE HEART. 33
forms a pear-shaped bag, the top or narrow extremity of which,
when the patient is horizontal, sometimes mounts even above the
second rib : its sides are nearly in contact with the sides of the
heart, while its front is separated from the anterior surface of the
heart, in the dead subject horizontally placed, by two or three inches
of interposed fluid.
From the above description, the auscultator will understand in
what situations to explore the lesions of the various parts of the
heart. In the section on Murmurs from Valvular Disease, it
will be shown that this knowledge is rendered available to the de-
tection of the individual valvular diseases, by a process so simple
as to divest the diagnosis of almost all difficulty.
The situation of the heart witli respect to the exterior is influ-
enced by a few other circumstances which remain to be specified.
The heart is, by its own gravitation, withdrawn, in some degree,
from the anterior walls of the chest when the subject leans or lies
back, especially if inclined a little towards the rig-lit side. The
same effect is produced by full inspiration, even in the erect posi-
tion. Under these circumstances, as the apex touches the walls by
a smaller point of contact, the impulse is weaker; and, as an in-
creased thickness of lung, a bad conductor of sound, is interposed,
the first sound is duller. On the contrary, when the subject leans
forward and a little to the left, the heart, displacing the lung by its
gravitation, comes in more than ordinarily extensive contact with
the walls of the chest. The same effect is produced by full expira-
tion, even in the erect position. Under these circumstances the
impulse is stronger, and the first sound louder. The auscultator
will know how to avail himself of these facts in the exploration of
disease, and will make due allowances in his estimate of the degree
of impulse and sound.
The percussion of the organ is so intimately connected with its
anatomical relations, that I may perhaps be allowed to sacrifice
strictness of arrangement to practical convenience, and advert to the
subject at present.
Percussion on the back of one or two fingers, firmly applied to
the chest, either on the ribs which is better, or on the intercostal
spaces if necessary, is sufficiently delicate for all practical purposes,
and is so convenient that I have, for seven or eight years, adopted
this, to the exclusion of all other modes of mediate percussion. I
must, however, admit, both from having attended the original ex-
perimental researches of M. Piorri, and from considerable subse-
quent experience, that the plessimeter invented by that gentleman,
when lined with wash-leather or cloth to prevent its clacking, is an
instrument of perhaps superior nicety, in the hands of one well ac-
customed to it.
It is scarcely necessary to say that percussion over a solid, as the
heart where it is in contact with the walls of the chest, elicits a
dead sound ; while that over a body containing air, as the lungs,
stomach, &c, produces a hollow sound. It is less generally known,
8 — e 3 hope
34 HOPE ON DISEASES OF THE HEART.
that a solid beneath a body containing air, as the liver beneath the
edge of the lung, the outline of the heart beneath the lung that
overlaps it, (fee., may be recognised by a sound intermediate between
hollow and dead. Had M. Piorri, to whom this discovery is due,
explained the principle of the phenomenon according to the laws of
acoustics, he would at once have made it obvious that what has
often been regarded as the offspring of his own imagination, was
the necessary consequence of an immutable law of nature. Thus,
when sonorous vibrations of the air impinge on a non-resonant or
inelastic surface, as drapery, they are arrested and the sound be-
comes deadened. The pedal and damper of a piano are construct-
ed on the same principle, the only difference being, that the check
is given to the vibrations of the wires themselves, instead of to those
of the air. Thus, when a note is struck, the vibrations continue
till the finger is raised from the key, simultaneously with which
action the damper falls on the wires, and by arresting their move-
ment suspends the sound. By depression of the open pedal, the
damper is permanently raised, and the vibrations then continue,
whether the finger be removed from the key or not. To apply this
principle to percussion of the chest, — sonorous vibrations excited in
the lung are arrested when they impinge upon a solid, inelastic
body beneath, as the liver, heart, &c. ; hence the sound is speedily
deadened or flattened ; in other words, the resonance is of a dull,
flat character : whereas, when there is no subjacent solid body, the
sonorous vibrations expand freely, and yield a proportionably hollow
sound. To elicit these characters distinctly, a loud sound should
be produced by strong percussion, and by pressing the fingers or
plessimeter firmly down, so as to condense the soft wall of the chest,
and render it a better conductor of sound. Having just tried the
experiment before several individuals placed at remote parts of a
spacious room, I find that they readily distinguish the full, hollow
tone of the middle lobe of the lung, the duller intonation of the lung
overlapping the heart or liver, and the dead sound of the prseeor-
dial region where the heart is in contact with the walls of the chest.
Now, it is the object of cardiac percussion to ascertain the ex-
tent of this dead sound or dulness, because, as observation has
demonstrated that it increases in proportion to the increased volume
of the heart, and vice versa, it indicates with considerable nicety
the actual dimensions of the organ. The mode of manipulation
which I employ, is to place one finger over the decidedly dead
part, and another over the slightly resonant edge of the lung, when,
by striking the two fingers alternately, the arched line along which
the organ lies in contact with the walls, may be traced with sur-
prising accuracy, unless the subject be remarkable for obesity,
which obscures the resonance. In females, the mamma may be
pushed upwards, which generally leaves the dull portion sufficiently
accessible.
The extent of the dull portion in an average-sized adult with a
well-proportioned heart, is represented by a circle of one and a half
EXPERIMENTAL RESEARCHES. 35
to two inches in diameter, supposing the individual to stand or lie
without protruding the chest, and in a middling state of inspiration.
When the heart is enlarged, as by hypertrophy, dilatation, fat,
or even temporarily by congestion, the descent of the lungs being
impeded, the dull portion increases and may attain the diameter of
three, four, or, in extreme enlargement, even five inches. The cen-
tre of the dulness generally lies between the cartilages of the 5th
and 6th ribs, but in great enlargement it lies lower, as between the
6th and 7th ribs, because the organ is depressed by its own gravi-
tation, except when held up by adhesion of the pericardium. In
copious hydropericardium, I have known the dulness ascend under
the sternum, in the conical form of the sac, as high as the level of
the second rib ; and I have repeatedly traced the gradual descent
of the dulness in proportion as the fluid was absorbed.
The causes which may prevent the development of dulness on
percussion are, 1. emphysema of the lungs, occasioning their pro-
trusion in front of the heart; 2. the chicken-breasted conformation
of the chest, especially when connected with spinal gibbosity. Of
the latter cause, though not mentioned by authors, I have noticed
many instances.
CHAPTER II.
ON THE ACTION AND SOUNDS OF THE HEART.
SECTION I. — Experimental Researches on the Action of the Heart.
When the ear or a stethoscope is applied to the prascordial re-
gion, two successive sounds, followed by an interval of silence or
repose, are distinctly heard. The first, which is synchronous with
the impulse, and, in vessels near the heart, with the pulse, is duller
and longer, very like that produced by jerking a cord as thick as a
swan-quill; the second is shorter, clearer, and smarter, like the flap
or click of a bellows-valve, or it is still more closely imitated by
lightly tapping the tense knuckle of one hand held close to the ear,
with the soft end of a finger of the other. These sounds, though,
according to Raciborski. not wholly unknown to Galen, Harvey,
Haller, Senac and Corvisart, were first brought into notice by Laen-
nec, and were attributed by him, the one to the ventricular, the
other to the auricular contraction. His doctrine remained unques-
tioned for a period .of eight or ten years, until Mr. Turner, supported
by the authority of the old physiologists, Haller, Harvey, Lancisi,
&c, pointed out that the auricular contraction, to which Laennec
attributed the second sound, preceded the ventricular, and, conse-
quently, that his theory was erroneous. Notwithstanding the talent
and ingenuity displayed by Mr. Turner in proving this, he was
not equally successful in assigning the cause of the second sound;
3*
36 HOPE ON DISEASES OF THE HEART.
and, though various theories were subsequently proposed, of which
I shall give a sketch at the end of this subject, the nature of the
heart's action remained a mystery, until it was made the subject of
a series of experiments instituted by the writer in the summer of
1830, and repeated in that of 1831. l
From experiments on small animals, supported by analogical
arguments derived from pathology, I had previously been able to
infer the nature of the heart's action, almost as I subsequently
found it; but the point required demonstration, and it appeared to
me that the only possible mode of effecting this was, by contriving
to hear the sounds at the same moment that the actions were in-
spected and felt: since thus alone could it be unequivocally ascer-
tained with what motions the sounds respectively coincided. Small
animals I had found insufficient for the purpose; as, in them, the
sounds are too indistinct, the motions too rapid, and the impulse too
feeble, to afford satisfactory data. To large animals, therefore, I
turned my attention, as presenting the only means likely to lead to
a solution of the question.
As many may wish to follow this investigation through all its
steps, and to form their own judgment from the data presented, I
insert an abstract of the whole of the original experiments, as pub-
lished in the Med. Gazette, July 31, and Aug. 21, 1830: and an
account of the conclusions presented by a repetition of them on
August 10th, 1831. I also insert,, in Section II. of this chapter,
my subsequent experiments on the sounds. The young reader
may, if he prefer, omit the whole, and pass on to the third chapter.
Experiments, July,3i, 1830.
As, in my opinion, it is impossible to avoid fallacies when the
heart is pulsating at the rate of two hundred per minute, I retarded
the circulation of the rabbits which I examined, by depriving them
of sensibility previous to the operation. Each pulsation was thus
resolved into several distinct and successive motions, which it is
philosophical to regard as an analysis of the more rapid natural
action. Under these circumstances I found the auricle to contract
1 These experiments were performed on the former occasion before Dr.
Hewett, Physician to St. George's Hospital; Mr. Smyth, House Surgeon,
and Mr. Lane, Lecturer on Anatomy to that institution ; Mr. Oswald Beale;
Mr. Frederick Julius, and Messrs. Field, Veterinary Surgeons. On the
latter occasion they were performed before Mr. Babington, Surgeon to St.
George's ; Dr. Burrow, Lecturer on Medical Jurisprudence to St. Bartholo-
mew's; Dr. Clark, Physician to St. George's Infirmary; Dr. Craigie, of
Edinburgh; Dr. Elliotson, Physician to St. Thomas's; Messrs. Field, Vete-
rinary Surgeons; Mr. H.J.Johnson, House Surgeon to St. George's; Mr. F.
Julius, Richmond; Mr. Mayo, Surgeon to the Middlesex Hospital; Mr.
Smyth, House Surgeon to St. George:s; Dr. Watson, Professor of Forensic
Medicine to King's College, and Physician to the Middlesex Hospital, and
Dr. Williams, author of the " Rational Exposition of Auscultation," &c.
Mr. Brodie, who was accidentally absent, favoured me with an account
of experiments by himself, which, so far as they went, coincided with my
own. See his letter, p. 47.
EXPERIMENTAL RESEARCHES. 37
first — not slowly — but with a motion so rapid as to be almost in-
stantaneous ; the moment the fluid reached the ventricle, the latter
was seen to start up, evidently by the contraction of its fibres on the
fluid which it contained, and not by passive distention. This was
more fully proved at a later period of the experiment, when the
action of the heart was from time to time suspended, and the ven-
tricle lay quiescent, though partially distended with blood; for,
then, the auricle often made two or three contractions, which had
no stimulant effect on the ventricle ; while a fourth, not more vio-
lent than the preceding-, and therefore not injecting more fluid,
caused it to spring up in the manner already described. Simulta-
neously with the springing up, commenced the retraction of the
apex towards the base, by which motion the apex was thrown for-
ward, apparently in consequence of the long axis of the heart as-
suming a more horizontal position. These actions constituted only
the commencement of the ventricular systole: its progress was
marked by a further retraction of the apex and an approximation of
the sides; while the whole ventricle was elevated further forward,
and its long axis rendered still more horizontal, by the auricular
distention, which advanced to its maximum in the same progres-
sion as the ventricle contracted to its extreme.
On examining the posterior aspect of the heart of a frog when its
action was reduced to fifteen or twenty per minute, the whole of
the auricle, which had previously been concealed by the ventricle,
being now exposed to view, it was found that, for a short space of
time, the ventricle lay at rest partially distended with blood; the
auricle then contracted with a smart brief motion — but only par-
tially contracted, for the sinus venosus was constantly full of blood
both in this experiment and those on the rabbit, and whether the
circulation was quick or slow. When the auricle had relaxed
again, and not till then, the ventricle (stimulated, I conjecture, by
the motion, for it certainly was not by distention) was seen suddenly
to rise up on its basis, to shorten its fibres, and to expel its contents,
which latter action was slowly performed. After the completion of
the systole, which was indicated by the pale colour, the diastole
took place, and allowed a partial influx of blood, denoted by the
return of the red colour ; and in this state the ventricle remained
quiescent for a short space, until again stimulated by the auricular
contraction. It may be objected to this account, that as the action
of the heart was pretcrnatu rally slow, the motions were anormal.
We thought, however, that we could discern the same series of ac-
tions when the pulsations were forty per minute.1 The Dublin
1 These, and various other experiments detailed in the Lond. Med. Gaz.,
were performed at Si. George's Hospital, in the presence of a number of the
medical officers and other gentlemen attached to that institution. To Mr.
Babington, Surgeon to St. George's, Mr. S. Lane, Lecturer on Anatomy to
the Hospital, Mr. Smyth, and Mr. H. J. Johnson, House Surgeons, I am
greatly indebted for their valuable aid in performing the experiments, and
their patient and unbiased scrutiny of the results.
38 HOPE ON DISEASES OF THE HEART.
Committee of the British Association for August 1835 have repeated
these experiments on the frog with similar results. They correctly
remark, that "in the heart of the frog, the sides of the ventricle are
thin, and the cavity is large ; and the increase of thickness of the
sides of the ventricle caused by the contraction of its fibres, is more
than counterbalanced by the diminution of volume of the ventricle
attendant on the expulsion of its contents :" — in other words, the
ventricle becomes very small during its systole because its walls
are thin, and very large during its diastole because, from the dis-
tensibility of the thin walls, its cavity is very capacious. In this
way they explain what I have frequently noticed, namely, that
"during the diastole of the ventricle, its anterior surface was pro-
tuberant and approached the sternum, while its apex drooped
towards the spine ; and that during its systole, the anterior surface
receded from the sternum, and its apex was slightly turned upwards
or towards the sternum." (Exp. 4.)
Experiments, August 21, 1830.
I now proceed to the communication of further experiments,
which, corroborated by pathological considerations hereafter to be
adduced, will, I trust, be found decisive of the long controverted
question respecting the cause of the motions and sounds of the
heart.
At the conclusion of my experiments and researches on small
animals hitherto detailed, I entertained the following impressions
respecting the state of the question : —
That, in small animals, the auricular systole took place imme-
diately before the ventricular, and not after, as supposed by Laen-
nec, 1 regarded as certain, both from the evidence of my own
experiments, and from the concurrent testimony of the old physio-
logists. It was to be presumed that the same occurred in larger
animals, but it remained to be proved.
That the impulse and first sound were referable to the ventricu-
lar, and not to the auricular contraction, I was equally persuaded,
1st, because the pulse, unquestionably the result of the ventricular
systole, coincided so closely, in vessels near the heart, with the im-
pulse and sound, that these three phenomena did not admit of
being ascribed to any but the same cause; 2d, because clinical ob-
servations had proved to me, that certain anormal modifications of
the heart's impulse and first sound corresponded with certain mor-
bid conditions of the ventricular, but not of the auricular parietes.
That the second sound did not depend on the auricular systole,
was indubitable; because this preceded the ventricular contraction,
whereas the sound followed it.
That it did not depend on the closure of the riuriculo-ventricular
valves was equally certain; because the closure of those valves
takes place at the commencement of the ventricular contraction,
whereas the second sound occurs after its termination. That it
was not due to any other action of the auriculo-ventricular valves
EXPERIMENTAL RESEARCHES. 39
was obvious from physical considerations of their anatomical struc-
ture. ■
Such were my impressions; but demonstrative proof was want-
ing, and it appeared to me that the only possible mode of obtaining
it was, by contriving to hear the sound at the same moment that
the action of the heart was inspected and felt ; since thus only could
it be unequivocally ascertained with what motions the sounds re-
spectively coincided. Small animals were obviously insufficient
for this purpose, as, in them, the sounds are too indistinct, the mo-
tions too rapid, and the impulse too feeble, to afford satisfactory
data. To the larger animals, therefore, I at once turned my atten-
tion, as presenting the only means likely to lead to a solution of
the difficulty.
The whole subject, then, seemed to resolve itself into the follow-
ing questions, which I drew out and proposed to my coadjutors,
before the operation, as the points for investigation : —
1. Do the auricles contract immediately before the ventricles ?
2. Does an interval occur between the two contractions, or is the
succession so rapid as to amount to continuity of action ?
3. Does the ventricular contraction cause the impulse, pulse, and
first sound?
4. Do the ventricles contract completely, and do they remain
closed and empty, during the interval of repose? Or —
5. Do the ventricles dilate again immediately after their systole :
and is this dilatation attended with an influx of blood from the
auricles?
6. Is the influx of blood into the ventricles during their diastole
the cause of the second sound ? If not —
7. What is the cause of the second sound ?
Experiment I. — An ass, of which the pulse and impulse were
forty-eight per minute, was instantaneously deprived of sensation
and motion by a smart blow on the head. The trachea was open-
ed, a large bellows-pipe introduced, and artificial respiration main-
tained; while, at the same time, the left ribs were sawn through
1 In the first edition, November, 1831, was the following passage : ': That
the first sound was not ascribable to the retrocession of the semilunar valves,
I entertained a strong presumption, from having found the sound unimpaired,
though the valves, on one side of the heart at least, were rigid with ossifica-
tion ; and the presumption amounted almost to certainty, from my having
found the sound not only undiminished, but increased, incases of enormous
dilatation of both ventricles, in which it was impossible that the cavities
could ever empty themselves ; and where, consequently, the motion of the
valves must have been impeded by the constant pressure of fluid on both
sides (vid. for instance, case of Lambert)." This reasoning has proved in-
correct ; for in the subjoined experiments on the sounds, I have furnished
demonstrative proof that the closure of the semilunar valves is the sole cause
of the second sound. I quote the above passage to show that 1 was no stran-
ger to the valvular theory — though some subsequent writers have thought
that the original idea emanated from themselves.
40 HOPE ON DISEASES OF THE HEART.
near the sternum, and forcibly bent back and broken,1 so as widely
and completely to expose the heart immediately behind the left
shoulder : the whole was accomplished in less than five minutes.
The pericardium was next opened, and the auricles and ventri-
cles fully displayed. The action of the heart was at first quick,
tumultuous, quivering, and irregular; but after the lapse of about
three or four minutes, it became regular and slower. The auricle
was now seen to contract first, and the ventricle instantly after-
wards; or, in more descriptive language, a slight contractile motion,
accompanied with very inconsiderable diminution of volume, was
observed to commence in the auricle, and to be propagated rapidly
to the ventricle. It was not, however, so quick thaf it could not
easily be followed by the eye ; yet it seemed to be rather a conti-
nuity of action, than to consist of two consecutive parts.
The ventricular contraction appeared, and was felt by the hand
to consist of a sudden energetic jerk, accompanied with a depres-
sion of the centre or body of the ventricle. This contraction was
heard (through the stethoscope, applied immediately to the organ)
to be accompanied by the ventricular sound. A note was accord-
ingly dictated,2 that, 1. The ventricular sound was heard whilst
the ventricle was seen to contract. At an interval of time equal to
that which intervenes between the first and second sounds of the
heart, the contraction was followed by a sudden, jerking re-expan-
sion or diastole, which appeared to elevate the body of the ventricle
more than the previous contraction. Hence one of the party (Mr.
Lane) expressed his opinion that it was the diastole, and not the
systole, that occasioned the impulse. This opinion rendered it ne-
cessary instantly to repeat all our observations. The stethoscope
was accordingly resumed, and several times applied by Mr. Field
and the writer alternately, each counting one. two, synchronously
with the sounds which he heard, and the impulse communicated
to his ear ; while others applied their hands to the ventricle, and at
the same time inspected its motion. It was now proved, to the
perfect satisfaction of Mr. Lane and all present, that the sound one,
and the impulse felt by the auscultator, coincided with the visible
depression (i. e. contraction) of the ventricle, and the impulse felt
by the hand. It was therefore dictated that, 2. When the action of
the heart was become slower, (supposed to be about forty per
minute,) and was becoming feeble, the ventricular systolic sound
and the impulse were heard, seen, and felt, both by the ear and
hand, to be simultaneous.
At an early part of the experiment it had been unanimously
agreed that the ventricle never contracted fully, though it was then
acting with great power. It was, therefore, dictated, that, 3. The
ventricular never contracted fully.
1 This plan was adopted in preference 16 cutting, in order to obviate
haemorrhage from the intercostal vessels.
2 The notes were written by Mr. F. Julius to the conjoint dictation of the
party during the progress, and immediately after the conclusion of each ex-
periment; and they were finally revised and signed.
EXPERIMENTAL RESEARCHES. 41
4. It remained apparently full during the interval of repose,
(i e. from the conclusion of the diastole to the commencement of
the next ventricular contraction.)
On interposing the hand between the apex of the heart and the
rib, which had been left above that part, the fingers were struck
vigorously by the apex of the ventricle during its systole, at the
moment that its body was in the act of retraction. 1
As the action of the heart, after ceasing to be tumultuous, became
somewhat feeble, the second sound was never very audible. It
was distinctly heard, however, by Mr, Field and the writer; but as
the others could not satisfactorily recognise it, a general note was
deemed inadmissible, and a by-note only was dictated, the point
being reserved for further investigation at the next experiment.
By-note. — Mr. Field and Dr. Hope listened with the stethoscope
alternately, and counted one, two, in unison with the sounds which
they heard ; while the others saw that one coincided with the ven-
tricular systole, and two with its diastole.
This first experiment was not considered conclusive. In con-
sequence of the turbulence of the heart's action at first, and its
feebleness at last, the time favourable for observation was toe brief;
and, consequently, a majority of the party had not complete confi-
dence in the accuracy of their observations. This diffidence
was shown by the second experiment to be greater than the case
warranted.
The second experiment was performed immediately after the
first.
Experiment II. — The heart of an ass was exposed to view in
the same manner as before, but with still greater celerity. For
about a minute only the action was quivering and irregular; it
then fell to its natural standard (forty to fifty per minute), became
perfectly regular, and the ventricular contraction, as felt by the
hand and the stethoscope, was performed with a power which can
scarcely be imagined from an examination on the outside of the
chest.
Three successive motions — namely, the auricular systole, the
ventricular systole, and ventricular diastole — were now distinctly
recognised and acknowledged by all who witnessed them. The
stethoscope was applied to the ventricle, and the two sounds were
clearly and unequivocally heard, even by those who were unac-
customed to the instrument. Five gentlemen listened deliberately
twice over, and two of them, three times, before it was dictated
that, 1st. Drs. Hewett and Hope, and Messrs. Lane, Field, and
Cooper, listened successively through the stethoscope applied to
1 This is corroborated by the London Committee of the British Associa-
tion repeating these experiments in August, 1836. "A small opening,1' say
they, " was made in the cartilages opposite the heart, when the stroke was
perceived and felt by the fingers inside and outside the sternum at the same
time, with sound, and with considerable pressure upwards against the fin-
gers placed between the heart and the cartilages.''
42 HOPE ON DISEASES OP THE HEART.
the ventricle, and severally counted one, hvo, synchronously with
the sounds which they heard ; while the others ascertained, by the
touch and sight, that the sound one coincided with the ventricular
systole, and the sound tioo with its diastole.
This part of the experiment was so deliberately performed that
it occupied from ten minutes to a quarter of an hour, as near as
could be judged from the whole time expended (from twenty to
twenty-five minutes), and each of the experimenters was asked
whether he was satisfied, whilst he had still an opportunity of
renewing his examination.
It was now submitted to investigation, how the ventricular sys-
tole could occasion the impulse; since the body of the organ
appeared to recede during that motion. The result was the follow-
ing note :
2. While the ear rested on the stethoscope applied to the middle
of the ventricle, the impulse was felt by the auscultator to coincide
with the systole, notwithstanding that the body of the ventricle
appeared to be receding at the moment the impulse took place.
During the course of the experiment the action of the auricle
was again examined. Its anterior edge and surface only were in
sight, the root and sinus being concealed behind the ventricle. It
was noted that —
3. The auricle never emptied itself, and its contraction was
always very inconsiderable. The anterior edge and surface were
seen to retract with a rather sudden motion ; but as the extent of
the motion was very inconsiderable, it had the appearance of being
feeble.
The contraction of the auricle was so much less than there was
reason to anticipate from the extent of its action in smaller ani-
mals, that it was questioned whether it was, in the present in-
stance, performed with the natural vigour. The extraordinary
power with which the ventricle acted, favoured the affirmative;
and as the proportion of the auricle to the ventricle is singularly
less in large animals than in small, there is reason to suspect that
they perform a less important function in the former.1
The inevitable conclusions deducible from these experiments
are, that — ■
Of the Motions of the Heart —
1. The auricles contract so immediately before the ventricles,
that the one motion is propagated into the other, almost as if by
continuity of action ; yet the motion is not so quick that it cannot
readily be traced with the eye.
2. The extent of the auricular contraction is very inconsiderable,
probably not amounting to one third of its volume. Hence the
1 In subsequent experiments on younger and smaller asses poisoned with
woorara, I found the action of the auricles greater than is here represented —
especially during palpitation, where the pulse was accelerated twenty or
thirty beats above its ordinary standard.
EXPERIMENTAL RESEARCHES. 43
quantity of blood expelled by it into the ventricle, is much less
than its capacity would indicate.1
3. The ventricular contraction is the cause of the impulse
against the side; first, because the auricular contraction is too
inconsiderable to be capable of producing it; second, because the
impulse occurs after the auricular contraction, and simultaneously
with the ventricular, as ascertained by the sight and touch; third,
because the impulse coincides so accurately with the pulse in
arteries near the heart, as not to admit of being ascribed to any but
the same cause.
4. It is the apex of the heart which strikes the ribs.
5. The ventricular contraction commences suddenly, but it is
prolonged until an instant before the second sound.
6. The ventricles do not appear ever to empty themselves com-
pletely.
7. The systole is followed by a diastole, which is an instanta-
neous motion, accompanied with an influx of blood from the
auricles, by which the ventricles re-expand, but the apex collapses
and retires from the side.
8. After the diastole, the ventricles remain quiescent, and in a
state of apparently natural fulness without distention, until again
stimulated by the succeeding auricular contraction.2
Of the Sounds.
9. The^rs^ sound is caused by the systole of the ventricles.
10. The second sound is occasioned by the diastole of the
ventricles.
The immediate causes of the sounds will presently appear in
the section on the Sounds.
Of the Rhythm.
Order of succession —
1. The auricular systole.
2. The ventricular systole, the impulse, and the pulse.
3. The ventricular diastole.
1 The preceding note perhaps justifies a belief that the auricular contrac-
tion is considerable in palpitation, and is greater in young and small
animals.
2 The Dublin Committee of the British Association for August 1S35,
have repeated these experiments and come to exactly the same conclusions:
viz. 1. " In the heart of warm-blooded animals, the systole of the ventricles
follows immediately the systole of the auricular appendices. 2. During the
systole of the ventricles, the auricles are distended by blood from the venous
trunks. 3. When their systole has ended, the ventricles become lax and
flaccid; and blood passes rapidly, but not with force, from the auricles into
their cavities. 4. The auricles are never emptied of their blood, and con-
tract but Utile on their contents, an active contraction being observable only
in their appendices. 6. The ventricles in their systole approach the front of
the thorax, and, by their contact and pressure against it, produce the impulse
or beat of the heart."
44 HOPE ON DISEASES OF THE HEART.
4. The interval of ventricular repose, towards the termination of
which -the auricular systole takes place.
Duration.
This is much the same as indicated by Laennec, viz.
The ventricular systole occupies half the time, or thereabout, of
a whole beat.1
The ventricular diastole occupies one fourth, or at most one
third.
The interval of repose occupies one fourth, or rather less.
The auricular systole occupies the latter part of the interval of
repose.
Experiments repeated, August 10, 1831.
Three asses were successively made the subject of operation,
the process being conducted as before. The gentlemen present
are enumerated at p. 36. It may be premised that, in consequence
of the percussion of the brain not having been, in the first instance,
sufficiently smart, the action of the heart was, in all three cases,
more or less irregular through the greater part of the experiment,
not continuing, as on the former occasions, ten or fifteen minutes
almost without the slightest intermission. Notwithstanding, as the
action was maintained for an equal, if not longer time, the periods
of regular pulsation were sufficiently numerous and prolonged to
allow of deliberate examination. The irregularity led to one im-
portant discovery which had hitherto escaped me ; namely, that
the movements of the ventricles with their corresponding sounds
c,on tin lied perfect while the auricles were motionless.
The following queries were circulated to the individuals present
a few days previous to the experiments. They were severally
read after each of the three experiments, and the answers were the
conjoint dictation of the party, partly during the experiments, and
partly at the successive recapitulations.
1. Do the ventricular systole, the first sound, the impulse, and
the pulse coincide?
A. They coincide perfectly, except that sometimes there appeared
to be a barely appreciable interval between the impulse or first
motion of the ventricle (as seen, and also felt with the fingers inter-
posed between the apex and the ribs) and the pulse in the radial
artery under the shoulder.
1 Mr. Bryan, however, performed the following ingenious experiment with
a different result. He caused a long tape to pass at a pretty uniform velo-
city across a table, and dotted it with ink in a hair.pencil synchronously
with each sound of the heart heard through a stethoscope. He found that
eleven inches of the tape passed on from the'time of the commencement of
the first sound to that of the second, and that twenty-seven inches more
passed before the next sound — thirty-eight inches passing during the time
of a whole beat. Thus the duration of the ventricular systole is less than
one third of that of the whole beat.— Lancet, Jan. 12, 1833.
EXPERIMENTAL RESEARCHES. 45
Remark. — The interval alluded to was ascribed to the distance
of the artery from the heart. In more remote arteries it is propor-
tionably greater, and in those near the heart it does not exist at all.
This subject had, I believe, been examined experimentally by
Dr. Stokes and Mr. Hart, of which I was not aware. The fact is
now well ascertained. The Dublin Committee of the British
Association, Aug. 1835, have illustrated it by a very pretty experi-
ment on a calf.
"A tube having been introduced through a puncture in the left
ventricle, and one of the mesenteric arteries having been exposed
and opened, the jet from the ventricle was observed to precede the
jet from the arteries, by an interval easily appreciable. The
femoral artery was opened, and a similar observation was made/'
(Exp. I.)
2. Do the ventricles expel the whole, or a part only, of their
contents; and what is their state during the interval of repose?
Are they full or empty?
A. The ventricles not being transparent, it is not demonstrable
whether they expel the whole of their contents: but the diminution
of their volume by the systole is not in general so great as to con-
vey that impression. During the interval of repose they are full,
being restored to that state by the diastole. By fnhicss, is not
meant distention, this being an ulterior degree.
Remark. — The question whether the ventricles expelled the
whole of their contents or not. originated in an opinion, which had
been maintained, that they did so, and. by the collision of their
internal surfaces, occasioned the second sound. As this sound is
proved to result from the diastole, the question becomes redundant,
and its determination unimportant.
3. With what motion of what part does the second sound co-
incide, and what is its cause? Is it the ventricular diastole ?
A. The second sound coincided with a motion, sensible to the
touch and sight, by which the ventricle returned from its systole
to the same state, with respect to size, form, and position, as before
the systole. This motion was the relaxation or diastole.
4. Do the auricles contract before, or after the ventricles, with
respect to the interval of repose?
A. Evidently before, being instantly followed by the ventricular
systole. The interval of repose distinctly falls between the ventri-
cular diastole and the auricular systole, the repose of the ventricles
continuing through the auricular systole to the next ventricular
systole. Such were the phenomena observed during the short
periods when the motions of the auricles were regular; but, for the
most part, there was either no perceptible motion in them, or the
motions were irregular and bore no relation whatever to the ventri-
cular movements.
Remark. — From subsequent experiments on rabbits, in the per-
formance of which I was favoured with the assistance of Dr.
Hewett, and Mr. Daniel, Surgeon, of Ramsgate, I am led to believe
46 HOPE ON DISEASES OF THE HEART.
that the irregularity of the heart's action is an incidental circum-
stance', dependent on the mode in which the animal is stupified,
and artificial respiration maintained: consequently, that it is
capable of being obviated. At the suggestion of Sir B. Brodie, I
stupified the rabbits in question by inoculating them with woorara
poison. In the first experiment, after the expiration of a few
minutes, stupefaction took place so suddenly that the action of the
heart was irrecoverably extinct before artificial respiration could be
established. In a second instance, arrangements having been made
to establish it more expeditiously, the action of the heart was main-
tained in the greatest perfection, after the cerebral life of the animal
had become completely extinct. We now found that, on tempo-
rarily suspending the respiration, the heart instantly became gorged,
of a black colour, and distended to nearly double its natural size,
while its motions were either an irregular, occasional flutter, or
were wholly suspended. On resuming the inflation, the motions
gradually became more and more frequent, extensive, and regular,
while the distention and blackness decreased in the same propor-
tion; until, at length, the organ regained its previous colour and
dimensions, and beat with its accustomed energy and regularity at
the rate of 200 per minute. This process was repeated again and
again for nearly an hour; and more than once, the action was
renovated, though with difficulty, after both the ventricles and
auricles had rested some seconds in a state of complete immobility.
Hence it appears that, when the stupefaction is complete, (as it is
from woorara poison,) and artificial respiration is adequately main-
tained, the action of the heart may be kept regular: and it was from
greater success in these two circumstances that, in my first experi-
ments on asses, the regularity was so remarkable. The hammer
employed had a smaller head, its surface, which was slightly exca-
vated, not exceeding an inch in diameter. By this, a corresponding
portion of the skull was depressed, whence the extinction of cere-
bral life was instantaneous and complete, and thus the performance
of artificial respiration was rendered more easy. I mention these
particulars, in order that, should it be found necessary to repeat
the experiments, an unnecessary destruction of life may be avoided.
I may add, that the experiments on the rabbit afforded an instruc-
tive exemplification of the manner in which congestion of the heart
takes place in excessive dyspncea, in suffocation, and in the agony
of death. They also showed how, under these circumstances, both
the impulse and sounds, even of the most enlarged heart, may
be diminished or become totally extinct. To return from this
digression —
5. Do the auricles contract slightly or extensively?
A. Yery slightly, and principally at, their appendix, the motion
running vernacularly into the ventricular systole.
Remark. — When several irregular ventricular contractions fol-
lowed each other rapidly, the corresponding diastoles were attended
with a slight retraction of the auricles, most conspicuous at their
EXPERIMENTAL RESEARCHES. 47
sinuses. This phenomenon proceeded from the increased suction
of blood by the ventricles.
6. Are the auricles ever empty, or are they constantly full ?
A. Constantly full, their motions ranging between fulness and
distention.
The following dictations formed a corollary.
" The first and second sounds were heard, and the correspond-
ing motions (the systolic and diastolic) were felt, while the auricles
were not contracting."
Remark. — Had this observation been made in my first experi-
ments, it would have superseded the necessity for much reasoning,
as it conclusively fixes the sounds, the impulse, and the back-stroke
or diastolic shock, on the ventricles.
"When the heart was gorged, towards the conclusion of the
experiments, the first sound only was heard. :?
Remark. — At the same time the action was very feeble. This,
as in the experiment on the rabbit, displays the cause of the diminu-
tion of sound and impulse in suffocative dyspnoea, and on the
supervention of death.
Sir B. Brodie, finding himself unable to attend these experiments
on the 10th, favoured me with the following communication on
the evening of the 9th. If doubt remains on the mind of any
respecting the points in my experiments to which his observations
refer, they cannot fail to have the weight which attaches to any-
thing that proceeds from the pen of this distinguished physiologist.
My dear Sir,
.... With respect to some of your propositions, I think that I
can already solve them in a way satisfactory at least to myself.
1. When I was making experiments on the circulation formerly, it
appeared to me that the pulse and the systole of the ventricle
exactly coincided. 2. It appeared to me that, when the action of
the heart was vigorous, the ventricles emptied themselves at each
contraction ; but that they did not do so, when the action of the
heart was feeble. 3. I never found the auricles completely empty
themselves, nor did I, in dogs, rabbits, dec. ever observe in them
any regular systole1 corresponding to, and alternating with, that
of the ventricles. I often used to observe several slight contrac-
tions of the auricle, especially of the appendix of the auricle, for
one of the ventricle. In frogs, however, I have a strong recollec-
tion that the actions did alternate and correspond, but, not being
able to find my notes, I cannot speak positively.
If I were to institute such a series of experiments, I would first
stupify the animal by inoculating him with the woorara, or some
poison of the same kind. You will observe that when an animal
is stupified with the woorara, there is no struggling, and you may
maintain the heart's action, by inflating the lungs, for an indefinite
1 Sir B. Brodie's observations were here imperfect.
48 HOPE ON DISEASES OF THE HEART.
period., I have some woorara, and can, T doubt not, furnish you
with enough for the experiment.
I am, dear sir, yours very truly,
B. C. Brodie.
The woorara arrived too late for the experiments on the asses. I
have already described how well it subsequently answered on a
rabbit. Prussic acid was tried on one ass, but the animal recovered
from four or five successive .drams given by the mouth, the poison
being bad.
SECTION II. — Experimental, Physiological, and Pathological Researches on the
Sounds of the Heart.
Though the experiments detailed in the preceding section fixed
the first sound of the heart on the ventricular systole, and the
second on the diastole, they did not go far enough to demonstrate
the immediate cause of the sounds. In the first edition of this
work, and previously in the Med. Gaz. of July 1830, I rejected the
view that the second sound was occasioned by the closure of the
semilunar valves, for the reasons above explained at page 38,
which I subsequently found to be erroneous. I also rejected, as
the cause of the first sound, the muscular "sound of rotation"
{bruit rotatoire), resembling the rumbling of distant wheels, first
described by Wollaston and Erman, and adopted by Laennec, as
attending the contraction and braced state of muscles, and Which
any one may readily perceive by applying his palm to his ear while
he alternately braces and relaxes his arm. (For all the particulars,
see Traite de l'Auscult. par Laennec, ii. p. 430, second edition). I
rejected this (and I have had no reason to alter my opinion up to
the present time), because, after torturing, and seeing others torture,
muscles in every conceivable way, I never could succeed in pro-
ducing, or thinking that others produced, a sound at all resembling
those of the heart, either first or second, in shortness and clearness;
for it must not be forgotten that the first sound, as well as the
second, is short and clear in naturally thin hearts, and in dilatation
of the organ. Nor has M. Bouillaud been more successful. After
a great number of experiments, he says, " There is not the least-
resemblance between the rotatory sound and the sounds of the
heart." Having thus excluded closure of the valves and rotatory
rumbling as the causes of the sounds, I too hastily adopted an
inferential explanation — that they were occasioned by the motions
of the blood. This explanation, never quite satisfactory to myself,
because not admitting of direct proof, was soon doubted by the pro-
fession. The valvular theory was received by Dr. Billing in May
1832; subsequently by M. Rouanet, who frankly and handsomely
avows that he derived the idea from Dr. Carswell in 1831 ; simul-
taneously by Mr. Bryan; afterwards by Mr. Carlile, and finally by
EXPERIMENTAL RESEARCHES. 49
M. Bouillaud, who adopted, with slight additions, the theory of
Rouanet. To Dr. C. Williams, who had already embraced the
theory which referred the sounds to " bruit musculaire," it still
appeared that the most simple and satisfactory way of accounting
for the first or systolic sound of the heart, was, to refer it to this
class of sounds (Rational Exposit. Appendix to 2d edit., p. 199,
Sept. 1833); while he was <: inclined to place the seat of the
second sound in the parietes of the ventricles rendered momentarily
tense by the sudden influx of blood." (Ibid. p. 201.)
Feeling it my duty immediately to correct my explanations, if
erroneous, I commenced a new series of hospital researches, on
the living and dead subject, in 1832, without, however, being ac-
quainted with the particulars of the valvular theories above alluded
to, most of which, indeed, had not yet appeared. I cannot refrain
from stating that the most able of the papers advocating this view
and refuting my own, was published by Mr. Bryan, a sensible and
vigorous writer, in the Lancet, August 6, 1833. He employs the
bulk of the arguments, and especially a case of my own (Anderson),
which had already led me to discard my old theory of the sounds.
I was not aware of the existence of this paper till 1838.
By examining a vast number of patients in the St. Mary-le-bone
Infirmary, I speedily satisfied myself that the first sound was
loudest over (or, as I subsequently found, below) the middle of the
ventricles; and the second, over the sigmoid valves, and thence for
a few inches upwards; also, that when a healthy subject was faint,
the first sound lost its prolongation, and became short and smart
like the second; whence I inferred that, in its natural state, it might
have a compound cause, viz. the closure of the valves, and the mo-
tion of the blood, or the bruit musculaire or rotaloire.
The presumptions, thus offered, that the valves were concerned
in the production of the sounds, required corroboration by experi-
mental and pathological evidence. Not having succeeded in satis-
factorily imitating the second sound by injecting fluids retrograde
into the aorta, I tried the expansion of membranes under water,
and found that three inches of fine tape, two lines broad, held to
the end of a stethoscope, and gently jerked under water, imitated
the second sound, both the sounds in dilatation, and the double
sound of the foetal heart, to perfection. Hence it was more than
probable that the sudden expansion of membranes so small as the
sigmoid valves was sufficient to produce such a sound as the
second.1
It was not easy to meet with satisfactory pathological cases on
this subject; as, to be conclusive, great disease of the valves on
both sides of the heart simultaneously, seemed to be required. The
case of Anderson was one of this kind; the mitral aperture being
1 M. Rouanet's experiments on membranes, &c. correspond with my own.
I tried every variety of membrane in breadth, extent, and thickness; also
silk handkerchiefs, cloths, &c.
8— f 4 hope
50 HOPE ON DISEASES OF THE HEART.
about a quarter of an inch, and the tricuspid half an inch in diame-
ter ; yet the second sound, though weak, was perfect and without
a murmur. Now, hstcl this sound been occasioned merely by the
influx of the blood, or any other cause than the sigmoid valves,
surely it would have been attended with a murmur.1
R. ST3 Esq. whom I saw in consultation with Dr. Armstrong-,
had a prolonged bellows murmur over the sigmoid valves instead
of the second sound. On examination, the orifice of the ossified
and dilated aorta was found so much enlarged that the valves did
not close it; hence resulted a murmur from regurgitation, which
extinguished the second sound. But why, it will be said, was the
sound not produced by the pulmonic valves? True; therefore, I
did not consider the case conclusive. I had elaborate notes of
three other similar cases ; but as the patients were living, the evi-
dence was still less conclusive. I had, however, notes of the case
of Thomas "Wood, in the St. Mary-le-bone Infirmary, Oct. 21, 1834,
made by myself and by Mr. Hutchinson, resident surgeon to the
institution, separately, attesting that a murmur from regurgitation
through the mitral valve completely drowned the first sound in the
vicinity of the valve. Whence it might be inferred that a murmur
in one set of sigmoid valves might possibly drown the natural
sound of the other set. I have subsequently ascertained that, over
the valves, this may actually be the case. But the natural sound
of one set of sigmoid valves can always be heard by listening two
or three inches up the vessel to which that set belongs, as its sound
is thus withdrawn from the murmur produced in the other set.
On the whole, therefore, the presumptions were exceedingly
strong in favour of the second sound being produced by the sig-
moid valves.
The evidence on the first sound, more fully explained in the
sequel, led me to establish the following presumptions; viz. that
the first sound was compound, consisting, 1. Of the valvular flap;
2. Of an augmentation of this, either from bruit musculaire, or the
motion of the fluid, or both ;2 3. Of the prolongation of the sound
by bruit ?nusculairet or the motion of the blood.
These presumptions required to be proved. No experiments
had hitherto been devised which afforded direct demonstrative
proof. M. Bouillaud, one of the last writers on the valvular theory,
and who published in 1835, says, "I will begin by avowing that
the proofs, direct or experimental, of the theory which we discuss,
are almost completely wanting, and probably ever will be want-
ing." (Traite,!. p. 133-4). After much reflection, a mode of
experimenting on the ass occurred to me in the autumn of 1834,
1 In November, 1837, I saw a case the precise converse of this: namely,
both sets of semilunar valves were disabled, and- the second sound was
almost completely extinct. These two cases afford as complete pathological
evidence on the point as could well be desired.
2 It will presently be seen that another cause, the sound of muscular
extension, was the principal source of this augmentation.
EXPERIMENTAL RESEARCHES. 51
which, if practicable, would inevitably, 1 thought, prove conclusive;
namely, after denuding- the heart in the manner described at page
39, to work out the following Propositions : —
1. Is the second sound loudest over the sigmoids, and is it so
near as to seem produced immediately under the stethoscope?
2. Is the first sound loudest over the two auricular valves re-
spectively ; and is it so near as to seem produced immediately
under the stethoscope?
3. Place the origins of the aorta and pulmonary artery between
the finger and thumb; apply the stethoscope on the heart near the
sigmoids; instantly after the ventricular systole, close the arteries,
so as to prevent the reflux of the blood and consequent expansion
of the valves, and see whether this annihilates the second sound.
4. Relax the fingers during the interval of repose, and see
whether this reproduces the second sound at its wrong interval.1
5. Push the knuckle, or the auricle, into each auriculo-ventricu-
lar orifice, so as to prevent the expansion of the auricular valves,
and see whether this annihilates the first sound.
6. Introduce a bent needle into the aorta, and hold open one or
more of the semilunar valves, so as to permit free regurgitation.
Notice whether this occasions a murmur with the second sound.
The pressure of the aortic system being thus thrown on the ven-
tricle, will it close the mitral valves? See whether this annihilates
the first sound on that side.
To pave the way for the performance of these experiments on
the ass, I first made trial on a rabbit, poisoned with woorara,
assisted privately and confidentially by Mr. H. James Johnson,
lecturer on anatomy at Kinnerton-street, and one of the proprietors
of that theatre. Though the heart acted vigorously for an hour,
and we could perfectly hear both sounds by applying the small
end of a thin stethoscope, the organ was too diminutive, and its
movements too quick, to admit of our appreciating modifications of
the sounds.
I then proceeded to a trial on the ass, at Mr. Field's, veterinary
surgeon, Nov. 3, 1834. For the purpose of obviating any possible
question respecting my title to the experiments as the inventor, I
took the precaution on this, as on all former occasions, of putting a
written copy of the above Propositions into the hands of the friends
invited, — Dr. Da vies, of Broad-street, Dr. C. J. B. Williams, Mr. H.
James Johnson, and Mr. Field. My woorara being exhausted, I
employed the hammer ; but the instrument being too round-headed
and the operator inexpert, the experiment failed, the action of the
heart being nearly suspended by the time that the organ was
exposed. The valves, indeed, were hooked back and the sounds
heard, but with unsatisfactory results. The heart was also cut
open, and its contractile movements were observed and listened to:
finally, we carefully examined the situations of the valves, and
1 This could never be accomplished.
52 HOPE ON DISEASES OF THE HEART.
practised the hooking of them up, with a view to a renewal of the
experiments. I made arrangements to renew them immediately,
and also requested, and was favoured with, a fresh supply of
woorara by Sir B. Brodie. From unforeseen causes, over which I
had no control, the experiments were delayed till the ensuing
February. The woorara was then employed, and the heart, when
denuded, beat with vigour and regularity about 60 or 70 per
minute, and continued so to beat for an hour — affording ample
leisure for making the following Observations, which answer to
the above Propositions. The observations, with two or three
exceptions only, were dictated and written by myself, under correc-
tion of the party, during the progress of the experiment. I publish
them verbatim from the original manuscript, a rule to which I have
always adhered. I therefore disclaim another version with verbal
alterations, giving, in my opinion, a slight bias in favour of the
exclusive muscular theory, which I believe to be erroneous.1
1 These experiments have been appropriated by a certain gentleman. At
their second performance, on November 3, 1S34, I promised him, from
friendly motives, the use of them for a forthcoming edition of his book; and
immediately before their final performance in February 1835, I permitted
him, as he expressed a wish, to become my conjoint associate, and subse-
quently lent him my own notes of the experiments, written almost entirely
with my own hand. He detained the notes, claimed the experiments, and
interdicted me from "pirating" them. An arbitration by Sir B. Brodie,
and a final agreement through Dr. Macleod, decided that the experiments
were conjoint, and that each should publish them as such. I did so (Appen-
dix to second edition, page v): he appropriated them. As he has, by this
measure, rejected the participation which I gave him, I resume my exclusive
right as the sole inventor. His bold pretensions to the invention (to which
he did not contribute directly or indirectly) are annihilated by a comparison
of my Propositions with the results and an examination of the date (Nov. 3,
1S34) when those Propositions were placed, in writing, in his hands; not to
mention the previous confidential performance of the experiments with Mr.
Henry James Johnson.
I am reluctantly compelled to make these remarks in consequence of
advantage having been taken of a mistake in Sir B. Brodie's arbitration to
show it to my disadvantage. Sir B. Brodie mistook the question, and
arbitrated as if I had interdicted the opposite party, and not he .me. Not-
withstanding, the result was entirely in my favour; for he decided (as I
contended) that the experiments were conjoint, not even questioning my
right to publish them: and he further bound the opposite party "carefully
to explain what share he (Dr. Hope) had in projecting and planning the
experiments in the first instance."
The following is from Dr. Thomas Davies, who assisted at the experi-
ment, November 3, 1834.
My dear sir,
I can truly say that, although I had read of the.movements of the valves
being the cause of the second sound, yet yours were the first experiments I
ever saw or heard of, for the purpose of attempting to prove it.
I remain, yours very truly,
Thomas Davies.
New Broad-street, July 21st, 1835.
EXPERIMENTAL RESEARCHES. 53
SERIES I.1
Obs. 1. The first sound was perfectly loud and distinct; and it
was louder on the body of the ventricles than over the semilunar
valves.
8, Suffolk Place, January 14, 1839.
My dear Hope,
I can have no hesitation in stating, that I first assisted you in making
some experiments on rabbits, to determine the causes of the sounds of the
heart, in the spring of 1830. These experiments were performed in the
rooms of the house-surgeons of St. George's Hospital.
The second occasion on which you did me the honour to ask my assist-
ance, was in the autumn of 1831, when we operated privately on a rabbit at
your own house. On this occasion you produced (to the best of my remem-
brance) the paper of " Propositions" to be verified or disproved, which you
have enclosed to me, and 1 never doubted that they were your own.
It was November 3, of the same year, that I was again present at a repeti-
tion of the former experiments, at Mr. Field's, when the paper, which I
believe to have seen previously, was reproduced.
Subsequently to this, my colleagues and myself had the pleasure of
placing the dissecting-room in Kinnerton-street at your disposal, for a con-
tinuation of the experiments on animals, at the first of which (for there
were more than one) I was present, but not at the remainder.
Yours very truly,
Henry James Johnson.
Notwithstanding what precedes, the individual alluded to writes as fol-
lows, in the last edition of the Pathology and Diagnosis of Diseases of the
Chest, p. 169 : " 1 concluded the Appendix (to the previous edition in 1832)
by recommending Dr. Hope to investigate experimentally these points (the
sounds of the heart), which were there shown to be doubtful; but his
engagements and other circumstances having prevented him from doing so,
I lately undertook the task; I made a point of ensuring Dr. Hope's presence
and testimony at the experiments, and I conferred with him and several
other gentlemen as to the best mode of performing them. I was present at
an experiment attempted by Dr. Hope, in November last, at Mr. Field's;
and he then planned modes of suspending the action of the valves, similar
to some of those afterwards adopted in my experiments." The last sentence
was added, I presume, to meet the order in Sir B. Brodie's arbitration. How
far it does so, and whether it is not rather an indirect appropriation of the
invention of the experiments, the reader can judge.
1 Present — Drs. Arnott and Williams, and Messrs. Babington, Smyth, H.
James Johnson, Peregrine, Good. Messrs. Charles Johnson and Tatum
were temporarily present.
These experiments were repeated, and republished a year and a half
afterwards, by the London Committee of the British Association. They
verified the whole, but without eliciting anything new beyond a few illus-
trations and corroborations, which I shall append in the form of notes to this
and the following series. The sameness is, perhaps, to be ascribed to the
circumstance, that one of the committee, who, as Dr. Todd informed me,
directed the others in everything, had been present at the whole of my
experiments. It was probably from the same cause that the committee
adopted the pure muscular theory of the first sound, previously advocated
by the same individual, and from which I dissent as being too exclusive.
" The subjects of their observations, say the committee, were, in most
instances, young asses, from three to six months old, apparently in good
54
HOPE ON DISEASES OF THE HEART.
2. The second sound was more audible over the semilunar
valves than at the other parts of the heart, being sometimes distinct
at the mouths of the arteries when inaudible on the body of the
ventricles.
3. Pressure on the arterial orifices by the fingers or the stetho-
scope invariably stopped the second sound. Slight pressure caused
a whizzing or bellows murmur with the first sound. l
4. The first sound was diminished, but not wholly suppressed,
by pressing upon the ventricles with the end of the stethoscope (so
as to curb or restrict their full contractile tension).
5. At each systole the sudden tension of the ventricles was such
as to produce an abrupt shock to the finger placed on any part of
them, with which shock the first sound exactly coincided. (This
observation was pointed out by the writer). 2
6. The first sound was diminished, but not suspended, by thrust-
ing the ends of the fingers into the auriculo-ventricular orifices;
the ventricles contracting less, and irregularly (from the impeded
influx of blood). 3
7. An incision being made into the left auricle, and the scalpel
being passecl into the ventricle, so as partially to destroy the mitral
valve, and the blood being allowed freely to escape, the first sound
continued to be heard with each contraction of the ventricle.
See 9 a.
health; and the mode of operation was, in a few instances, poisoning with
woorara ; in others stunning by a blow on the head; but in the majority,
the animal was pithed."
The successful experiments were fourteen in number, but the committee
say that they were " much less fortunate than several preceding experi-
mentalists, having, in no one subject, been able to continue their observa-
tions for a longer period than forty -five minutes." The report is ably drawn
up by Dr. Clendinning.
1 The committee observed that heavier pressure caused " a loud bellows
or rasp-sound" (Exp. 7). The same occurred in my Obs. 14.
2 The committee say " at each systole, while the heart acted vigorously,
the ventricles i'elt to the finger as hard as cartilage" Again, "The ten-
sion and hardness of the ventricles during their systole were very remark-
able." (Exp. 14).
3 The committee here say " A first sound was heard, prolonged by a
whizzing murmur" (Exp. 9 and 12). Again, "The inversion of the auricles
was accompanied with a sensation of thrilling in the finger of the operator,
synchronous with the impulse" (Exp. 10 and 12). The murmur and thrill,
I had noticed a year previously (See Obs. 26, in the third Series). Also,
" On inverting the auricles again, the chordae tendineae of the mitral valve
alone, were felt to become tense in systole, and lax in diastole" (Committee
Exp. 12). This observation militates against the experimenters' own
theory: viz. that the first sound is purely muscular and independent of ex-
tension of the valves and their chordae. Again, " The finger being intro-
duced into the left ventricle by inversion of the auricle, was felt to be gently
embraced and pushed, as if by a membrane distended with blood. On the
right side, nothing similar was unequivocally observed" Exp. 14. This ob-
servation also, by showing the tense state of the membrane of the valve,
opposes the theory of the experimenters.
EXPERIMENTAL RESEARCHES. 55
8. The sound continued, though the right auricle was com-
pletely cut open.
9. And, finally, though the finger was introduced into the left
ventricle, and was made by pressure to prevent the influx of blood
into the right ;
a. Its character, however, was not so clear and smart as when
the ventricles contracted on their blood ; 1
b. Thirty or more contractions, the majority very vigorous, took
place after the incision had been made. 2
SERIES II.3
Obs. 10. Before the pericardium was opened, both sounds were
very distinctly heard.
11. Both were also distinctly heard through the lung interposed
between the heart and the end of the stethoscope.4
12. About two or three inches up the aorta from its origin, the
second sound was heard (but not the first), alternating with the
impulse as felt on the ventricles. (This observation was suggested
by myself (not by Mr. Kcate), in consequence of my having pre-
viously noticed the same in the living subject, as stated at p. 49).
13. The second sound was decidedly more distinct over the
origins of the aorta and pulmonary artery than on the body of the
ventricles; and, in that situation, it was louder than the first sound
at the same point. It had exactly its natural short, clear, flapping
character.
14. The aorta and pulmonary artery being compressed between
the fingers, the first sound was accompanied with a loud murmur,
and the second was stopped.
15. A common dissecting hook was passed into the pulmonary
artery, so as to prevent the closure of the semilunar valves : the
second sound was impaired, and a hissing murmur accompanied
it. A hook was passed into the aorta, so as to act in the same
way on the aortic valves: the second sound entirely ceased, and
was replaced by a prolonged hissing. (Heard by several.)
16. When the hooks were withdrawn, the second sound returned
and the hissing ceased.
17. Experiment 15 was repeated, and whilst Dr. Hope listened,
1 The committee say "The first sound was still distinctly heard by all,
but weak" (Exp. 7).
2 I had made incisions in all my previous experiments, both in 1S30, 1831
and 1834. The idea, therefore, though not specified in the propositions,
cannot be claimed by one who had attended those experiments.
3 Present Drs. Williams and Macleod, and Messrs. Keate, Partridge,
Malton, Goode, Seagrim, and others who looked in only temporarily— in-
cluding Mr. Henry Johnson. Mr. Tatum was absent. The heart acted
vigorously for an hour.
4 I made this observation to refute the contrary opinion heLd by M. Ma
jendk'.
56 HOPE ON DISEASES OF THE HEART.
the hook was first withdrawn by Dr. Williams from the aorta.
Dr. Hope immediately said, "I hear the second sound."
IS. Dr. Williams then removed that from the pulmonary artery;
Dr. Hope said, " the second sound is stronger, and the murmur has
ceased." (Several listened to 16, 17, and 18.)
19. The arteries were cut open: the heart continuing to con-
tract (about eight or ten times), the first sound only was obscurely
audible. '
SERIES III.
On August 7th, 1S35, six months after the two preceding series,
I performed the following, at the Kinnerton-street Theatre, assisted
by Dr. Latham, physician to St. Bartholomew's, Dr. Wntson and
Mr. Mayo, physician and surgeon to the Middlesex Hospital, and
Mr. Thorpe, a student of St. George's Hospital. My principal ob-
ject was to ascertain, with more precision, to what extent the auri-
cular valves were subservient to the production of the first sound,
and I had projected a new experiment (see below, Obs. 26) with this
design.
A large ass, aged 8 or 9, with a pulse at 40, was employed.
Having formerly found six or eight grains of woorara barely suf-
ficient to kill an animal, and generally in not less than half an hour,
and having only two grains of the poison remaining, I adopted the
following process, which was singularly successful, the heart having
acted no less than two hours after the death of the animal, which
is an hour longer than in any other experiment with which I am
acquainted, except those of the Dublin Committee of the British
Association, performed about the same time, August 1835. " The
period," they say, "varied in diiferent subjects from one to two
hours.
The jugular vein having been denuded by Mr. Mayo at the ordi-
nary bleeding point, which is the most superficial part of the vein,
and the finger having been passed round it, a small incision was
made in the vessel, just sufficient to admit an ounce syringe
charged with a solution of the two grains of woorara in an ounce
of water. This being injected, the aperture was pinched up with
the forceps and secured by ligature. Respiration instantly began
to fail, in less than a minute it had nearly ceased, and in a minute,
1 The committee say " The pulmonary artery being cut across, the first
sound was still loud: and the aorta being then cut across likewise, the same
result was obtained — viz. a first, without a second sound. The heart was
then severed from its several attachments, and the systolic sound was still
heard distinctly. The heart was then grasped strongly under blood : it con-
tinued to contract vigorously, and the first sound was heard (but not loud)
wiih the flexible tube as well as the common stethoscope. The heart was
then taken out and held in the hand of one of the committee : when the first
sound was distinct, but feeble. On opening the right ventricle, the columnae
carneae were distinctly seen contracting simultaneously with the ventricle"
(Exp. 14).
EXPERIMENTAL RESEARCHES. 57
wholly. The trachea was then opened, a bellows pipe introduced,
and artificial respiration established. The chest was next opened
by sawing through the ribs (which were ossified) close to the
sternum, and making two incisions along the intercostal spaces to-
wards the spine, so as to include three or four ribs, which were
then broken backwards. Large vessels were secured in the course
of the operation to prevent hemorrhage, because, by taking off' the
tension of the vascular system, it diminishes the loudness of the
sounds.
The heart, when denuded, was beating steadily and with sur-
prising power, about sixty per minute, and it continued to beat
between forty and seventy per minute for two hours, the frequency
increasing above sixty, whenever, from diminishing the inflation
or from compressing the lungs with the hand, the supply of blood
to the left side of the heart was insufficient, which was indicated
by the flabbiness and diminished size of the left ventricle.
The results (which I have numbered consecutively with the
two preceding series) were as follows: —
Obs. 20. The first sound is audible through interposed lung.
21. Tiie second sound is loudest over the sigmoid valves, and
for two or three inches along the aorta and pulmonary artery.
22. The first sound is loudest over the parts of the ventricles
nearest to the auricular valves.
Having in my written Propositions for the present series re-
quested the experimenters to " make observations on the shock of
the ventricles at their maximum tension/7 the following' was the
answer : —
23. The impulse from lateral expansion was greatest at the mar-
gins of the auricular orifices, there throwing the finger out with a
violent jerk. The lateral expansion of the base (i. e. upper part)
of the ventricles attended the retraction of the apex.
24. On lightly placing the finger and thumb on each side of the
pulmonary artery, opposite to the valves, a shock corresponding
with the closure of the valves was distinctly and repeatedly felt by
Dr. Latham, Mr. Mayo, and myself (Dr. Watson having retired);
and I felt the same on applying my finger to the aortic valves.
The same observation was made, a year later, by the London
Committee of the British Association, but they had the priority of
publication in their Report, August 1836. Their words are,
"Immediately after the systole, a flapping or jerking sensation was
sensible to the finger applied to the arteries at their roots" (Exp.
10). Again, "on touching the arteries in the vicinity of the
valves, a sensation of flapping (or jerking) was observed by all,
commencing immediately after the systole, and accompanying the
second sound" (Exp. 13).
This observation proves nothing, but it corroborates others by
conveying to the mind a strong feeling or impression of the force
and smartness with which the semilunar valves close, and of the
58 HOPE ON DISEASES OF THE HEART.
sufficiency of such membranes, so closed, to produce such a sound
as the second.
25. A hook was passed into the pulmonary artery and the valves
held open. This created a sighing murmur instead of the second
sound, previously very distinct. The hook being withdrawn, the
murmur ceased and the second sound returned as distinct as before.
This was repeated three times with the same result.
On the last occasion the hook got entangled, and on withdrawing
it, the sighing murmur, with diminution of the second sound, con-
tinued permanent ; which I predicted to indicate an injury of the
valve, as was subsequently found to be the case ;
This valve being injured, and about an hour having elapsed, I
did not venture to hook up the aortic valves, lest I should be pre-
vented from making the next observation (No. 26), which was the
main object of the experiment, and from which I hoped for im-
portant results. On formerly trying my Proposition No. 5, viz.
" push the knuckle or the auricle into each auriculo-ventricular
orifice, so as to prevent the expansion of the valves, and see whether
this annihilates the first sound," I had found, in Series I. and II.,
that pushing so large a body as the auricle into the orifice, pre-
vented the influx of blood, and thus disturbed the regularity and
completeness of the heart's contractions : I therefore devised the fol-
lowing mode of accomplishing the same object.
26. I passed a needle of flexible wire through the insertion of the
left auricle, and out at the opposite side, and then bent the needle
into the ventricle, so as to prevent the sudden expansion and closure
of the mitral valve.
This greatly diminished the first sound and created a very loud
murmur from regurgitation, which I also felt to be attended with a
strong thrill (fremissement cataire) at the margin of the auricular
orifice.
Hence the loudness of the first sound is connected with the closure
of the valves, but this experiment does not prove that the valves
are the sole cause of the sound, because the regurgitation would
diminish the tension of the muscular walls and, consequently, the
sound produced by it. We occupied an hour in making this single
observation, trying it in every way and with the utmost care ;
when the action of the heart suddenly and spontaneously stopped,
and put an end to the experiment.
Autopsy. — One of the pulmonic valves presented an oval aper-
ture from laceration by the hook, capable of admitting a large quill,
thus realising my anticipation that this was the cause of Ihe per-
manent murmur from regurgitation.
An interesting appearance was noticed along the margins of the
aperture and at several points of the pulmonary artery and interior
of the ventricle, where the lining membrane had been lacerated by
the point of the hook: namely, the parts were overspread with a
EXPERIMENTAL RESEARCHES. 59
number of pink, semitransparent, fibrinous coagula, the size of pins'
heads, and easily removable with the handle of the scalpel. Their
characters, in short, were closely analogous to those of ordinary
valvular vegetations. It may be a question whether they proceeded
from inflammatory exudation of lymph, or from mere entanglement
of blood by the broken surface. The former view is perhaps the
more probable.
[Report of Experiments on ike Action of the Heart, by C. W. Pennock
and E. M. Moore.
Impressed with the importance of the experiments to illustrate the heart's
action, instituted a few years since by some European physiologists, we had
resolved, more than a year past, to repeat them upon the first favourable op-
portunity. We were the more anxious to perform them, as the subject is
one that has received but little attention in this country, and the profession
seems scarcely aware of its importance. Circumstances, however, prevent-
ed us from carrying our designs into effect until a short time since; when
upon application to an intelligent victualler in a neighbouring village, every
facility was afforded us. We have been assisted by several medical gentle-
men ; but to Dr. Hardy, of the Philadelphia Hospital, who aided us in all
the experiments, may be mainly attributed their successful results. We
were also kindly assisted by Dr. Wood, Resident Physician of Frankford
Asylum, Dr. Stille, of Pennsylvania Hospital, and Mr. Burns, of Mobile.
Before proceeding to detail the experiments, we may say that the stethos-
copes or ear-trumpets used were flexible, constructed of a coil of wire,
covered with gum elastic and silk; one, about four feet long, the ear-piece
and hollow cone for the reception of sound, being of horn ; the other, about
two feet long, the ends composed of biock- tin, and smaller than the first.
This instrument is essential to the success of the experiment, as the impulse
is so great with the ordinary stethoscope, as to render the analysis of sound
very uncertain. In measuring the heart, the ordinary shoemaker's measure
is used, by which very accurate results may be obtained. Artificial respira-
tion was maintained by the bellows, at eighteen to twenty inflations of the
lungs per minute.
Experiment 1st. — Present, Drs. Hardy, Wood, Pennock and Moore.
A ram about one year old was selected.
Owing to the alarm of the animal, it was found extremely difficult to
ascertain the natural pulse and respiration; but during the time he was most
quiet, the former ranged from ninety-six to one hundred ar.d eight per
minute, and the latter from thirty to forty in the same time. The stethos-
cope, applied to the left side of the chest, opposite the fourth rib, revealed
the sounds of the heart distinct and normal, but faint. Upon the sternum,
in the same line they could scarcely be distinguished. The animal was
then deprived of sensation by several blows upon the anterior portion cf the
cranium; and the bellows-tube being immediately introduced through an
incision of the trachea, respiration was artificially sustained. An incision
was then made down upon the sternum, and extending its whole length,
with a knife whose edge was purposely roughened to prevent haemorrhage.
The bone was then divided longitudinally by a saw, and its parts separated
by hooks, thus presenting a cavity of six or eight inches in diameter. Ten
minutes had elapsed from the time the blow was given until the chest was
opened, but the heart was still observed to bent irregularly and very rapidly.
The excitement, however, soon subsided, and the heart pulsated regularly,
and with a frequency of ninety-six per minute. The stethoscope was first
applied to the heart — the pericaidium being still unopened — and the sounds
were observed to be of the same character as previously observed, but much
louder. The first sound appeared to occupy about one half of the whole
60 HOPE ON DISEASES OF THE HEART.
time of a pulsation; this was followed by the second which is about one
half as' long as the first, or one fourth of the whole, and is more flapping
than the first ; the remaining time is occupied by repose.
The head of the auscultator being averted, and his eyes closed, the end
of the stethoscope "was applied by an assistant to the base near the valves,
and to the body of the heart alternately; and it was decided by each in
succession, that the first sound was louder over the body of the ventricles
than near the valves, while the second sound was much more distinct near
the valves, than over the ventricles elsewhere. The change, however,
modified the second sound much more than the first. A portion of the lungs
being interposed, we found the sounds duller, but in other respects of the
same character. The anterior portion of the pericardium was then remov-
ed, and the heart exposed, presenting the right ventricle and auricle, and a
small portion of the left ventricle, the auricle being concealed behind the
heart. During the ventricular systole, the right ventricle was observed to be
flattened, and the finger and stethoscope being applied, the first sound and
impulse occurred at the same time. During this contraction the base of the
heart revolved for a short distance to the left, supposed to be about one six-
teenth of a circle, while the apex turned to the right at the same moment,
thus causing the heart to assume a spiral form during the systole. The
transverse diameter was much diminished by this systole; during diastole it
increased, and the heart assumed a rounded appearance. The stethoscope
was again applied in the same manner as heretofore detailed, and with the
same result. A comparison being instituted, with the head averted as be-
fore, between the character of the sounds over the right and left ventricle,
it was unanimously conceded, that on the right, the first sound was flapping
and shorter than on the left, while on the latter it was prolonged and rush-
ing. The first sound, impulse, and ventricular systole, were synchronous.
There was, however, an appreciable difference between the contraction of
the ventricles, and the pulse, increasing as the distance from the heart was
greater. The pulse varied from eighty-four to ninety-six, becoming irregu-
lar when the artificial respiration was omitted or too rapid.
The heart pulsated two hours after opening of the chest.
Experiment 2d. — Present, Drs. Hardy, Pennock and Moore. A ram,
about a year old, whose pulse was irregular, but seventy-eight per minute,
was selected lor the experiment, on account of the slowness of the heart's
pulsation, which facilitates the analysis both of the sounds and motion. Sen-
sation was destroyed by blows upon the head, as in the preceding experi-
ment, and the chest opened as before, but the heart beat feebly and irregu-
larly, being congested, and expelling but a small portion of its contents.
The sounds were feeble over the right ventricle, (not observed over the left,)
and the second soon disappeared entirely; but the first sound remained,
whilst the heart contracted, which ceased to beat in a short time.
Experiment 3d— -Present, Drs. Hardy, Pennock and Moore. A ram, six
months old, was chosen; pulse, 102; respiration, 32. Was struck upon the
forehead anterior to the horns. Some difficulty was experienced in intro-
ducing the tube connected with the bellows, and in opening the chest. Fif-
teen minutes elapsed before the heart was exposed. It was found congested
and its action irregular. The sounds were more feeble, and the heart con-
tracted less forcibly than in the first experiment, but the coincidence be-
tween the impulse and the ventricular systole were the same, as were also
the spiral motion, the peculiar character and succession of the sounds, as
well as their comparative intensity at the base and body of the heart. Sus-
pecting from the experiments of others, as- well as from the facts we had
observed, that the semilunar valves were concerned in the production of the
second sound, we attempted to elevate them by hooks introduced into the
aorta and pulmonary artery, and note the effect upon the sounds. In co'nse-
quence of puncturing the artery, hemorrhage succeeded, and we failed in
our purpose. The heart, while still beating, was removed from the body,
EXPERIMENTAL RESEARCHES. 61
and the stethoscope applied to the ventricle. It continued to contract many-
times while in the hand, and during contraction, a sound resembling the
first sound was heard, differing only in being more feeble. But one sound
was heard. The ventricles were then slit open longitudinally, and emptied
of blood, and the same sound was elicited. Pulse lell at one time to 84 per
minute. Heart beat three fourths of an hour.
Experiment Ath.— Present, Drs. Hardy, Pennock and Moore. A ram,
about a year old, was opened as in experiment 3d. Our attention was now
directed exclusively to raising the semilunar valves, but without success.
The heart was again removed as -in former experiment, the ventricle and
right auricle cut open, and emptied of blood, and the fingers thrust into the
apertures, thus elevating the tricuspid and semilunar valves. A sound pre-
cisely similar to that in the last experiment was detected, but less intense.
Experiment 5th. — Present, Drs. Hardy, Wood and Moore. A ram, about
a year old. We administered two drachms of Allen's Prussic Acid, contain-
ing ten drops of the pure acid. Spasmodic breathing was induced in a few
seconds. At the expiration of one minute and a half, the trachea was opened ;
and respiration established at the end of two minutes. Immediately upon
cutting through the integuments, no blood was observed to flow. At the end
of four minutes, the heart was exposed, but perfectly motionless and enor-
mously distended.
Experiment ^th. — Present, Drs. Hardy, Pennock, Moore and Mr. Burns.
The animal, an ewe, one year old. Deprived of sensation as before. Opened
in fifteen minutes. Heart contracted irregularly at first. Same character of
first and second sound; same relation of pulse, impulse and ventricular
contraction, and same comparative character of sounds upon the left and
right ventricles as in first experiment. Heart did not contract vigorously as
in first experiment, and when the right ventricles became congested, the
second sound disappeared over it. The contractions of the two ventricles
were also synchronous. The heart being allowed to rest upon the collapsed
lungs, the apex was not observed to rise. The heart during the contraction
of the ventricle diminishes transversely, but elongates about one fourth of an
inch, as measured from base to apex. We again failed in elevating the
valves. The heart was removed as in experiments 3d and 4th, with the
same results.
Experiment 7th. — As those experimenters who had preceded us had found
greater success upon the calf, we procured one about nine days old. It was
deprived of sensation by a blow upon the occiput. Some difficulty was ex-
perienced in opening the trachea, and two minutes had elapsed before arti-
ficial respiration was commenced ; and upon opening the chest, life was
extinct ; a few very feeble contractions being observed in the right ventricle.
Experiment Slh.— A calf, five days old, pulse one hundred and thirty ;
respiration, thirty-two. Both sounds heard distinctly through the chest.
The animal was struck upon the forehead, immediately above the frontal
sinus. The chest opened as in first experiment. Same spiral motion ob-
served during contraction. The elongation at the same time one fourth of
an inch, as measured from union of aorta and ventricle to the apex. The
whole heart has an apparent motion from the base towards the apex, and
the pulmonary artery turns partially around the aorta, which is a fixed
point, describing about thj arc previously mentioned. The same flattening
of right ventricle during its contraction as before observed. When the
stethoscope was placed upon the aorta, two inches above the valves, both
sounds were heard, but the second sound much louder than the first. Over
the pulmonary artery both sounds were faint, but especially the second,
which disappeared as the heart became feeble. A curved needle was passed
into the aorta, but the sounds were indistinct, and the second appeared to be
absent sometimes, and not at others, when the hook was in the artery.
Upon examination after the removal of the heart, it was found that the valves
were sometimes elevated, and at others not.
62 HOPE ON DISEASES OF THE HEART.
Experiment 9th. — Experiencing great difficulty in analysing some of the
movements and sounds of the heart in animals of the size upon which we
had experimented, we resolved to inspect the heart of a horse, in which the
pulse in health ranges from thirty to forty per minute. In this experiment
we were assisted by Drs. Gerhard, Stewardson, Peace, Hardy, Fell and
Goddard, but to the latter gentleman, especially, we owe our thanks for the
assistance rendered.
We found in the animal we had selected that the pulse was about thirty-
six per minute, and respiration twenty-eight in the same time.
In order to prolong life, the trachea was opened before the blow was given.
Immediately after the blow was struck, which was directed to the forehead,
that the skull might be depressed upon the anterior lobes of the brain, the
bellows-tube was introduced, and artificial respiration commenced. The
skin was dissected back from the median line upon the thorax, the cartilages
of the ribs sawn through upon the left side of the sternum, and several of
the ribs cut off about one third of their whole length from their sternal ex-
tremity. On account of the hemorrhage, we were obliged to secure many
arteries, and twenty-five minutes had elapsed from the time the blow was
given until the heart was exposed. It presented the left ventricle, the ap-
pendix of the left auricle and a portion of the right ventricle. The pulsa-
tions were one hundred per minute, but on account of its size we were
enabled to observe the relative contraction of the auricle and ventricle, which
we found to succeed each other as follows : — During the contraction of the
ventricle, the auricle dilates; at the expiration of the systole, the auricle
contracts, and the diastole of the ventricle commences, the auricular con-
traction apparently occupying about one half the time of the ventricular
diastole. During its systole, the left ventricle flattens and elongates. During
its diastole it shortens, and assumes a rounded form. The sounds were
detected, but not loud; the second not existing over the pulmonary artery,
but heard over the body of the left ventricle.
Death arrested the further progress of the experiment, twenty minutes
after the chest was opened. * * *
Although every experiment had confirmed our views of the agency of the
valves of the aorta in the production of the second sound, we had heretofore
failed in elevating them ; we were also still doubtful respecting the relative
contraction of the auricle and ventricle, for, although the last experiment
had appeared more satisfactory on this point than several of the preceding,
yet, as life continued but a short time after opening the thorax, and as many
circumstances unfavourable to clear and calm observation were connected
with the experiment, we resolved to pursue the investigation of these obscure
points, and to exhibit the facts that we had observed to a few medical friends.
Experiment 10th. — Present, Drs. Gerhard, Goddard, Stewardson, Peace,
Hardy, Pennock and Moore. A ram, about six months old. Pulse, ninety-
six. Deprived of sensation by a blow upon the head, and opened as in ex-
periment 1st. The heart contracted well, but exhibited great irritability
when touched. Its pulsations rose to one hundred and fifty per minute, ren-
dering it difficult to analyse the sounds; but the first sound and impulse
were observed to coincide. The spiral motion and elongation were as here-
tofore detailed. While still contracting forcibly, the heart was removed
from the body, and the first sound heard when entire, and also when both
ventricles Avere cut open and emptied of blood.
Experiment llth. — As the last experiment had not been very satisfactory,
the same gentlemen being present, we pursued the investigation upon a calf,
four weeks old. Pulse, one hundred and five. Both sounds distinctly heard
through the chest. Struck upon anterior portion of the cranium, and opened
as before. The pericardium was left entire, to avoid the irritation of imme-
diate contact with the heart. The stethoscope was placed alternately upon
the aorta, the body of the right ventricle, and upon the septum, near the
EXPERIMENTAL RESEARCHES. 63
apex. Upon the aorta the second sound was found to predominate ; upon
the body of the right ventricle it was scarcely heard, and the first was pre-
sent ; and near the apex upon the left ventricle, or septum, both were detected;
the first, louder. The spiral motion, the elongation, and elevation of the
apex as before observed. A hook was passed into the aorta by Dr. Moore,
and one of the semi-lunar valves elevated ; the eyes of the auscultator were
closed, to prevent the possibility of bias from preconceived opinions. While
in this position, the auscultator announced the absence of the second sound,
and the accession of a rough bellows sound in the first sound. The hook
was then withdrawn, and the second sound was declared to have returned.
This experiment was tried twice by each, and by some three times in suc-
cession, and the results were uniform. No hook was passed into the pulmo-
nary artery, inasmuch as no sound was heard over it at this time. The
auricle contracted while in the hand, emptied of blood.
Experiment \2th. — A ram, six months old. Present Drs. Stille, Hardy,
Pennock and Moore. Pulse, ninety-six; respiration fifty-six. Animal struck
upon forehead, as in the previous experiments, and artificial respiration
established in three fourths of a minute. During the opening of the chest,
much hemorrhage took place. The heart was at first tumultuous in its
action, but became regular in a few minutes. The first and second sound
were heard over the body of the right ventricle, but more feebly than over
the left; both sounds were heard over the left ventricle and aorta, but the
second louder than the first over the latter than over the former. Hooks
were passed into the ventricle, for the purpose of keeping open the auriculo-
ventricular valves. (These, however, failed of effecting the object, as seen
upon examination afterwards.) The sounds gradually became more feeble
as the heart congested, and the second sound ceased altogether, both over
the heart and arteries, while the first still remained. The auricle was ob-
served to contract over its entire surface, as much upon the body as upon the
appendix. The contractions with reference to the ventricles were irregular
at this time, except for a very short period, when they appeared to precede
those of the ventricle immediately, recurring at the termination of repose.
The heart contracted one hour after the blow was given.
Experiment V3th. — Wether, nine months old. This experiment failed on
account of defect in the apparatus for maintaining respiration. As the heart
became more feeble, the auricle appeared to contract immediately antecedent
to the systole of the ventricle, but owing to the circumstances attendant
upon this experiment, we feel very uncertain as regards tire observation.
. Experiment lAth. — Ewe, nine months old. Struck as before. Trachea
opened in half a minute. Chest opened in four minutes. Heart tumultu-
ous. It gradually became more quiet, until it fell to one hundred and twenty,
and contracted forcibly. The first sound alone wras heard over the right
ventricle and pulmonary artery. Pressure upon this artery produced a bel-
lows sound in the first sound. The auricles were pushed into the auriculo-
ventricular openings by the fingers. The first sound was thus rendered
much more feeble, and lost its sharp character; the ventricles contracting
imperfectly and irregularly.
Experiment ihth. — A calf, five days old, pulse, one hundred and twenty-
six ; respiration 30. Sensation destroyed by a blow upon the head, as before.
Artificial respiration established in two minutes and a half. The heart was
exposed in six minutes, rather hurried in its action, but soon fell to one hun-
dred and twenty pulsations per minute. The heart contracted with a
moderate force. The second sound extremely feeble over the body of the
right ventricle and pulmonary artery ; but it soon disappeared over both.
The sound was still heard over the left ventricle and aorta, louder over the
latter. The auricle contracted with a quick motion, the contraction not
being confined to the appendix, but extending over the whole body of the
organ. As the heart became weaker, the pulsations were slower, and we
were enabled to analyse the relative contractions of the auricle and ventricle
64 HOPE ON DISEASES OP THE HEART.
much better than at any previous experiment. They evidently bore a dif-
ferent relation from what we had previously supposed. The succession is
as follows: — First the auricle contracts, and the action is immediately pro-
pagated to the ventricle, which contracts, instantly, accompanied with the
diastole of the auricle ; the diastole of the ventricle immediately follows,
accompanied with a subsidence of the auricle by passive and not active con-
traction, which partially fills the ventricle; then follows the state of repose,
at the termination of which, the auricle contracts. During the dilatation of
the auricle, the vena cava also dilates, but it Was difficult to say, whether
the cava dilated during the contraction of the auricle or not, as the con-
traction of the latter was so rapid and so soon followed by the contraction
of the ventricle. While still contracting, and when scarcely any sound was
heard upon the ventricles, the stethoscope was applied to each auricle, and
a sound similar to the first was heard, but very short, and more flapping,
resembling very nearly the first sound of the foetal heart.
Experiment 16th. — A calf, two months old. Pulse ninety. Deprived of
sensation as before. The chest was opened in eight minutes, and a i"ew
ribs removed from the left side. The heart pulsated slowly, and at a rate
of ninety -five per minute ; both sounds were distinct, but not loud. The
second sound was heard more loudly over the pulmonary artery than on the
right ventricle, the sound being but feeble in either position. Both sounds
were heard upon the left ventricle. An instrument was introduced into the
left ventricle, through the auricle, and the mitral valves prevented from col-
lapsing; this produced congestion of the ventricle immediately, and the
action became hurried and irregular. The stethoscope being applied to the
left ventricle, the sound was not as loud and clear as before, but not modi-
fied in any other manner. The instrument was then withdrawn, and the
sound became loader. The relative contractions of the auricles and ventri-
cles were as in the last experiment.
The difference in the intensity of the first sound in this experiment, when
the mitral valve was kept open and when allowed to close, may be attri-
buted to the fact that there was no fixed point for the muscle of the ventri-
cle to act upon, by the retention of the blood, and it therefore could not empty
itself of its contents, and, of course, would not yield a strong sound.
From the preceding experiments we draw the following conclusions:
1st. The pulse is synchronous with, and caused by, the ventricular con-
traction,— and when felt externally, arises from the striking of the apex of
the heart against the thorax.
2d. The expulsion of the blood from the ventricles is effected by an ap-
proximation of the sides of the heart only, and not by a contraction of the
apex towards the base; during the systole the heart performs a spiral move-
ment, and becomes elongated. (Experiments 6th, 10th, and 11th.) ■
3d. The ventricle contracts and the auricle dilates at the same time,
occupying about one half of the whole time required for contraction, diastole,
and repose. Immediately at the termination of the systole of the ventricle,
its diastole succeeds, occupying about one fourth of the whole time, syn-
chronous with which the auricle diminishes, by emptying a portion of its
blood in the ventricle, unaccompanied with muscular contraction. The re-
maining fourth is devoted to the repose of the ventricles, near the termina-
tion of which the auricle contracts actively, with a short, quick motion, thus
distending the ventricles with an additional quantity of blood: this motion
is propagated immediately to the ventricles, and thfir systole takes place,
rendering their contractions almost continuous. (Experiments 15 and 16.)
4th. From the termination of their diastole to the commencement of their
systole, the ventricles are in a state of perfect repose, their cavities remain-
ing full, but not distended, while those of the auricles are partially so, during
the whole time.
5th. The sounds are produced by the motions of the heart or its contents,
and not by striking against the thorax, as proved in all the experiments;
EXPERIMENTAL RESEARCHES. 65
being much louder when the stethoscope was applied directly to the heart,
than when to the chest, or with the lungs interposed.
6th. The sounds are more distinct when the muscle is thin, and contracts
quickly. Hence, the clear, flapping character of the first sound over the
right ventricle, as compared with the left.
7th. The first sound, the impulse, and the ventricular systole, are synchro-
nous. This sound may be a combination of that caused by the contraction
of the auricles, the flapping of the auriculo-ventricular valves, the rush of
blood from the ventricles, and the sound of muscular contraction. From
experiments 3d, 4th, 6th, and 10th, when the heart was removed from the
body, the ventricles cut open and emptied of their contents, the auriculo-
ventricular valves elevated, and a sound, resembling the first, still heard, it
may be chiefly attributed to the muscular contraction. That these valves
aid but slightly in its production, may also be inferred from Experiment 16.
8th. The second sound is caused exclusively by the closure of the semi-
lunar valves from the reaction of the arterial columns of blood upon them,
in its tendency to regurgitate through the aortic and pulmonary orifices.
This is proved by the greater intensity of this sound over the aorta than
elsewhere, the blood having a strong tendency to return through the valvu-
lar opening ; by the greater feebleness of the sound over the pulmonary
artery, which is short, and soon distributes its blood through the lungs, thus
producing but slight impulse upon the valves in the attempt to regurgitate;
by the disappearance of the sound, when the heart becomes congested and
contracts feebly; and, finally, on account of its entire extinction when the
valve of the aorta was elevated.
9th. The second sound is synchronous with the diastole of the ventricle.
From these experiments, it will be seen that our conclusions coincide
very nearly with those of the British physiologists, — the correctness of
whose results, when compared with those of the French, may be mainly
attributed to the use of larger animals. From our observations, calves, of
from four to eight weeks old, are decidedly preferable to other quadrupeds
for these investigations. The tenacity of life of calves of this age is greater
than in older animals, whilst the cardiac pulsations are slower, and more
forcible, than they are in the younger. The heart of this animal, too, is of
large size, and the introduction of hooks for the elevation of the valves is
readily effected.
The English and Irish physiologists enjoyed great facilities in the slow
and regular action of the heart, as induced by the woorara. Perhaps, at
some future period, when this may be obtained, the investigations may be
pursued, as other points of enquiry are offered.
C. W. Pennock,
E. M. Moore.
Philadelphia, Nov. 2, 1839.
Experiments on the Motions and Sounds of the Heart,
By the London Committees of the British Association for 1838-39 and 1839-40.
Experiments for 1839-40.
In consequence of having been appointed to conduct the experiments on
the motions and sounds of the heart for the current year, without being asso-
ciated with any colleagues, I thought it desirable to avail myself of the as-
sistance of such of my friends, including the other members of last year's
committee, as could attend, and I accordingly requested the co-operation of
a considerable number of gentlemen known to the public. Of ihese, several
were able to attend on numerous occasions, and one of them, Dr. Boyd,
Resident Physician of the St. Marylebone Infirmary, on every occasion, so
that every observation and experiment has been witnessed by one, or in
most instances several, of the following gentlemen; to several of whom I
am indebted for very important assistance: —
8 — g 5 hope
66 HOPE ON DISEASES OF THE HEART.
Professor C. J. B. Williams; George Gulliver, Esq., F. R. S; John
George Perry, Esq.; Dr. G. Hamilton Roe; Dr. George Burrows; Charles
Cochrane, Esq.; Dr. Rutherford; Francis Kiernan, Esq., F. R. S. ; J. Sid-
dell, Esq.; T. K. Pritchard, Esq.} Francis Samwell, Esq.; Dr. Edwin
Harrison; R. A. Stafford, Esq.; Benjamin Phillips, Esq,, F. R. S.; Dr.
Robert Boyd, and other gentlemen, private friends of the Reporter, and the
last four named gentlemen, his colleagues in the staff of the St. Marylebone
iDfirmary.
The experiments were performed in a convenient locality immediately
adjoining the St. Marylebone Infirmary, and principally on donkey colts of
a few months old. In the latter part of the series other animals, and espe-
cially dogs, were used, partly for economy and in order that the limited pe-
cuniary resources at my command might not be prematurely exhausted ; and
partly because certain experiments contemplated were expected to prove
more easily and decisively practicable on the larger heart of the ass, than on
any smaller, such as that of the dog: and that in any event it was desirable
to extend the range of observation as far as practicable over the animal scale.
The mode of preparation was in all cases nearly the same. In almost
every case, sensibility was withdrawn as completely as was practicable, by
one method or other. In donkeys, I availed myself of the stupefying pro-
perty of the woorara poison, for a packet of which I had been indebted since
1838 to Sir B. C. Brodie. The woorara was brought into operation by in-
jecting a couple of grains of it, partly dissolved, partly suspended in water,
into the external jugular vein, as practised by Mr. Mayo in an experiment of
Dr. Hope's, and the injection was usually fojlbwed in a very few minutes,
by complete insensibility. In smaller animals prussic acid was used in
several instances, and in a few the subject was stunned by a blow on the
head. Artificial breathing was used in every warm-blooded subject, by
means of a bellows and long flexible tube kept loose in the trachea; the
chest was opened, nearly as directed by Galen (de admin, anat.), and as
practised by former committees, and five or six ribs, at least, were separated
from the sternum, and broken near the articulation, and bent back over the
vertebrae. In every case, whether during the preparation or subsequent ob-
servation, all convenient means were used, as advised by Galen, to prevent
or lessen hemorrhage, in order to avoid, as much as possible, the anomalous
modes of action attending extreme vascular depletion, and to prolong the op-
portunities of observation and experiment.
The observations about to be detailed consist partly of experiments in
continuation of the inquiries of former commitiees, and partly of experiments
conceived and performed with a view to decide several points in dispute
amongst physiologists of authority, which were not investigated, by those
committees, and which seemed to me yet unsettled, and at the same time
important enough to call for direct experimental investigation. The follow-
ing are the principal of those undecided questions.
1. With respect to the rhy thm of ihe motions of the auricles and ventricles,
several living distinguished physiological writers appear to hold, that those
cavities act in strict alternation with each other, and not continuously or in
immediate succession, the auricles being first in systole and diastole, and the
ventricular actions being last before the Rest, as described by Steno, Har-
vey, Lancisi, Haller, Senac, &c. ; and by Hope, Williams, Carlile, Pen-
nock and Moore, and other distinguished living experimentalists.
2. With respect to the share in the circulation due to the auricular systole,
it has been declared to be active, and of much importance, by Harvey, Senac
and others; while several living writers of great weight, adhering apparently
to the views of Galen, Vesalius, &c, seem disposed to refuse to the auricles
any very influential or positively important share in the cardiac operations;
for examples, I may cite Dr. Elliotson, Prof. Bouillaud, Dr. Hope, Sir B. C.
Brodie, &c.
3. With respect to the shape and dimensions of the ventricles in systole.
EXPERIMENTAL RESEARCHES. 67
it was held by Galen, Vesalius, Harvey, &c, that the heart is shortened in
diastole, and lengthened in systole; but the observations of Steno, Lower,
Lancisi, Haller, and others, gave currency to opposite views. Of late,
however, the ancient opinion has been received ; for example, by Professor
Burdach and Professor Bouillaud, as I understand their observations, and by
Drs. Pennock and Moore, the latest experimentalists on the subject that I
know of, except my friends and myself.
4. With respect to the precordial impulse, the great majority of physiolo-
gists, adhering unqualifiedly to the ancient opinion, advocated by Hippo-
crates and Galen, amongst the Greeks, and by Vesalius, Harvey, Lancisi,
Senac, Haller, Hunter, &c, ascribe the cardiac pulsation to a blow or stroke
(in the popular meaning of those words) given by the heart's apex in systole
to the ribs : and refer the apparent inaction in the heart, between its pulsa-
tions, to the retreat of the organ during its diastole inwards, and away from
the walls of the chest. But in opposition to this view may be cited the ex-
periments of several recent observers, and the arguments of Mr. Carlile, of
Dr. Hope, (in his last edition,) of Mr. Bryan, of Dr. Billing, &c. dec.
5. With respect to the diastole of the heart, it was held by Galen and
Vesalius to include a strong force of suction, by which principally the venous
current was forwarded and the auricles were emptied; and this power of
inhalation or suction has been adopted by numerous living authorities; e.g.
Professor Bouillaud, Dr. Hope and Dr. Copeland ; and has even been ex-
tended to the auricular diastole, e. g. by Professor Allison and Dr. Elliotson.
The exertion, however, of any such force has been distinctly denied to the
diastolic state by Harvey, Lower, Senac, &c; and recently by Dr. Billing
and Dr. Arnott, as physical absurdities, and the opinion appears, Dr. Joy
remarks, to rest on no satisfactory experimental evidence whatsoever.
6. In addition to active pulsations observed in certain animals in the veins,
(as in hares, rabbits, dogs, fowls, frogs, &c.,) there have been noted by
several experimentalists, of whom it is sufficient to name the great Haller,
certain passive pulsations, viz., an abrupt diastole of the vein attending the
first part of the heart's systole, or the auricular contraction, and an abrupt
systole of the vein attending the first part of the heart's diastole, or the dila-
tation of the auricle ; but the connection between this venous regurgitation
and the auricular systole has been doubted by several apparently, and even
doubted by Dr. Elliotson.
7. Reverting to the auricular function, the systole of the auricles has
usually been regarded as unattended by any intrinsic sound. Dr. Hope de-
nies that any such sound occurs, and on physical grounds seems to affirm
that it is not possible ; and Dr. Joy calls the auricular systole a " silent" act.
(Library of Practical Medicine.) Six months probably, or more, however,
before the London commissioner for 1840 had even begun his experiments,
Drs. Pennock and Moore had, unknown to him and his friends, detected, as
they conceived, an auricular systolic sound in a series of very interesting
experiments, of which an account is published in the American Journal of
Medical Science, No. 50, February, 1840.
S. The following often agitated and still moot points have appeared to
the Reporter in like manner to stand in need of further examination : e. g.
1, the sizes of the cavities, &c, with respect to each other; 2, the produc-
tion of sound by certain muscles while vigorously contracting; 3, the rhythm
of the cardiac and arterial pulse, &c. &c. Finding on all the preceding
points considerable difference of opinion, and perceiving that, in many in-
stances,the decisions of highly distinguished and leadingphysiological writers
were at variance with what he considered to be the best hitherto recorded
experiments and observations, the Reporter found forced on his mind the
conviction that on all or most of those points further data were wanting, and
experiments less ambiguous, and more pointed and conclusive. Under such
impressions the Reporter felt himself at liberty, if not positively called on,
to advert to the various questions above alluded to, which had not been
5*
68 HOPE ON DISEASES OP THE HEART.
handled by former committees, provided that by any unlooked for good for-
tune, if not through some new and happier experimental combinations, he
should 'succeed in eliciting pertinent and decisive facts. Acting on such
views, he has put to the test of experiment, to a greater or less extent, several
of those questions, with results now to be stated.
It may be proper to mention that the instrument used in auscultation was
exclusively the flexible ear-tube ; the wooden stethoscope, inconvenient in
most cases, being found quite unsuited for such experiments.
Conclusions from both series of experiments and observations, viz. those of
1838-39, and those of 1839-40.
MOTIONS.
1. That the order of the motions of the auricles and ventricles is by con-
tinuous succession rather than by alternation of actions. The auricles con-
tract abruptly after the rest or pause, and the ventricles immediately after
the auricles, without any distinct interval between the successive systoles;
and the diastoles of the cavities follow in somewhat similar order, viz. the
auricular diastole coinciding with the ventricular systole, and continuing
after ; and the true rest or pause of the heart being constituted by the dias-
toles of auricles and ventricles together, and in reality, though not in a man-
ner sensible externally, ceasing on the recurrence of the auricular systole:
and this rhythm of the motions seems to be universal, and common to warm
and cold blooded animals. '
2. That the visible systolic and diastolic motions are first perceived at the
bases or fixed parts of the cavities, viz. in the auricles at the sinuses, and in
the ventricles at the fundus cordis, and that the apices of the auricles and
ventricles, or free parts, are brought into full action after the other parts, and
only just before the supervention of the opposite and next succeeding con-
dition of the cavities respectively, whether that condition be systole or dias-
tole.
3. That in systole the heart is diminished (except only in such regions or
parts of the organs as may have been previously compressed or collapsed,
during the unresisting flaccidity of the diastole), and then its long axis in
particular is strikingly and invariably shortened.2
4. That the normal systolic action of the auricles is energetic and almost
instantaneous, and quite universal: the manifestations of contraction in the
appendix perceptibly succeeding to those of contraction in the sinus, although
by a very minute interval ; and that the normal auricular diastole is gradual,
continuous, and wholly passive, and is effected by an influx of blood from
the cava progressively distending the cavity from sinus to apex, and from
the termination of one systole of the cavity to the commencement of the
succeeding one.
5. That the systole of the ventricles is gradual in its developement, and
complex in its phenomena; part of these phenomena being attributable to
contraction in the muscular parietes, and part to reaction on the part of the
fluids. By the muscular contraction the heart is made to compress the
1 The only exception known to the Reporter, from books or observation, seems ap-
parent rather than real, viz. an alternation of action, as noted by Lancisi, in the chick
in ovo, and by several observers, for example, in cases of very rapid cardiac action.
In such cases the diastoles have been so hurried and short (owing-, no doubt, to very
rapid and copious influx from the veins,) that the systoles of the ventricles have been
closely approximated to each other, and the intervening rest_been apparently suppress-
ed, and an apparent alternation of systole and diastole without intervening rest been
produced.
2 This statement is diametrically opposed to the observations of Drs. Pennock and
Moore. In every experiment on the heart's action, they invariably found that organ
was elongated during its systole. As this point is an extremely interesting physiologi-
cal problem, it will speedily receive further investigation.
EXPERIMENTAL RESEARCHES. 69
blood, which resists in all directions alike, and thrusts out the previously-
flattened, depressed, or collapsed sides of the ventricles, and effectuates in
great part that shortening of the organ, that is required to admit of closure
of the auri-ventricular valves; and this reaction of the fluids mainly con-
tributes under certain favouring circumstances of position, &c, to cause the
motion that has been described as tilting of the apex, ccc, which motion is
principally, (the Reporter believes exclusively.) a result of the elevation of
the long axis of the heart in systole, caused by the assumption of a convex
or globular form in the central parts of the organ, instead of the superiorly
and inferiorly or laterally compressed state of the previous diastole.
With respect to diastole, it appears that the ventricular diastole or dilata-
tion is wholly passive, exerting no influence over the venous current, or the
motion of the arterial valves, and is partly effected by an influx of blood
from the veins commencing at the moment of relaxation of the ventricles,
and continuing until the succeeding systole, and reinforced immediately
before the latter by an abrupt influx from the auricles.
6. That the pulsations of the veins are of two kinds, at least in some ani-
mals, viz. both active and passive ; and the latter or passive pulsations,
which, on the authority of Haller, may be held to exist in all animals, are
attributable to reflux from the auricles in their systole.
7. The precordial throb or pulsation is caused, immediately, by the
undulation of the blood in its resistance to sudden muscular compression in
the systole of the ventricles. This reaction of the fluids is first perceived
about the fundus of the ventricles, and last about the apex, towards which it
seems to be propagated by a continuous undulation from the fundus with
extreme rapidity. In consequence of this reaction of the blood, the heart's
sides ate rendered convex, instead of compressed or flattened as in diastole,
and are, in the middle parts more especially, heaved outwards from the
central axis abruptly and with great force. Thus on all parts of the surface
of the organ an impulse is fell in systole, which is greatest there, when, in
addition to placid flaccidity of walls, there has been collapse in the diastole
(viz. the central parts), and which is least when such collapse has previously
been wanting or slight (viz. the apex). This cardiac impulse is usually
perceived in the healthy subject, over the apex only, owing to its being
absorbed and neutralised over other parts of the heart by an interposed thick
mass of spongy lung.
The heart does not oscillate on the aorta, or move to and fro in the chest
from systole to diastole, and vice versa; nor does it suffer any changes in
consequence of its own efforts, and exclusively of movements of the lungs
and diaphragm, excepting in its shape and size, and in the thickness and
tension of its parietes, and the capacities of its cavities. The doctrine that
the precordial pulsation is caused by a blow received by the ribs, in conse-
quence of the heart's "jumping" (ax/ux, Hippocrates,) or striking against
them ("pectus ferii," Harvey. — " Costam ictu perculit," Haller, &c. &c.)
appears to be superfluous with a view to explanation of phenomena (not-
withstanding the ingenious illustrations of the ancient opinion by Senac and
Hunter), and to be substantially unfounded in point of fact.
8. That the arterial diastole or pulse, almost every where outside of the
pericardium, perceptibly succeeds to the cardiac systole, though near the
heart the interval between them is very brief, and, to unpractised observers,
difficult to distinguish.
SOUNDS.
9. That the first sound of the heart depends partly, but, in a slight degree,
on the abrupt closure and transitory tension of the auri-ventricular valves,
which gives to this sound much of its sharp well defined beginning; but
that the first sound is mainly attributable to cardiac muscular tension alone,
and that its prolonged duration is owing in great part to the progressive
character of the full systolic effort from fundus to apex; and that this sound
70 HOPE ON DISEASES OF THE HEART.
is in no degree attributable to any blow or stroke of the heart against the
ribs.
10. That the auricular systole is attended by an intrinsic sound resem-
bling that of the ventricles, but more short, obtuse, and feeble. This auri-
cular systolic sound is often more difficult of detection, even on the naked
heart, and with tolerably vigorous action of the auricles, owing to its being,
to the inexperienced ear, absorbed in, or masked by, the immediately suc-
ceeding and much louder systolic ventricular sound.
11. That the sounds of friction in pericardites may, when well marked
and under ordinary circumstances, be expected to be double at least, and
they may be not improbably triple or more. In its systole each cavity of the
heart moves so as to cause a friction of its attached lamina in one direction
against the adjacent lamina of the pericardium; and in its diastole a peri-
cardial friction is caused by each cavity in an opposite direction; and as the
auricular appendices move to and fro independently of the ventricles, the
normal pericardial frictions must be, as direct observation shows them to be,
quadruple, or double with the auricles, and double with the ventricles. If,
therefore, those frictions were rendered sonorous by the interposition of any
rough substances between the rubbing surfaces, (as lymph for example), and
supposing the heart's actions sufficiently vigorous, we might, under ordinary
circumstances, anticipate with confidence, a duplication of murmurs at least,
one systolic and one diastolic. Now this duplication of sounds must be the
principal element in the acoustic diagnosis of pericardites, since effused
lymph may be of any thickness, consistence, extent, &c. &c. and may be
situate on any portion of the heart's surface between its nearest part and its
furthest, and may. therefore, cause friction sounds of the most variable seat,
depth, and character. But, of course, another physical means of distinction
of great importance remains, viz. the comparatively equable diffusion ol the
sounds of pericardial friction all around the seat of attrition rather than in
any one or exclusive direction.
12. That the sounds of the structurally healthy heart are much liable to
modification by deviations from the normal standard in the condition of the
fluids, and in the order and force, and equability of action of the carneag
columnse, and other contractile parts governing or influencing the action of
the valves, and the closure and opening again of the orifices of the ventricles ;
and this dependence of the heart's sounds on conditions material or dynamic,
wholly excluding structural defect, is so considerable that the second sound
may, in the normal heart, for a time be very variously modified, or masked
by strange murmurs, or even apparently suppressed, in consequence of
hemorrhage, or from the introduction of poison into the veins; and the first
cardiac sound, though never wholly wanting during the active existence of
the heart, may still, under similar circumstances to those just referred to,
present various abnormal features ; may, ex. gr. be as short as the second
sound, or be attended or followed by anomalous murmurs, and be otherwise
strikingly modified.
13. Other conclusions, more or less satisfactorily deducible, as the Re-
porter conceives, from the facts stated, are, that the peculiar sounds occur-
ring in pericardites, and attributable to pericardial frictions, are not referable
only to vascular turgescence, or to abnormal dryness, &c. of the pericar-
dium, but to lymph effused by and adhering to that membrane, or other
similar obstacle to the easy and noiseless gliding over each other of the ad-
jacent parts of the pericardium.
14. That the ventricles are of equal capacity during life, and that the in-
equality usually met with after death, is an illusion, as explained long since
by Harvey.
15. That the suction influence upon the venous circulation, attributed to
inspiration by various writers, is well founded.
16. That the action of the long muscles, and more especially those of the
abdominal parietes, is attended by an intrinsic sound. The notice of this
EXPERIMENTAL RESEARCHES. 71
fact by the Reporter has been rendered necessary in consequence of some
attempts at verification, and some criticisms on an experiment of the Lon-
don Committee for 1836-37, published in the last edition of Dr. Hope's ex-
cellent work on the heart.
17. That the sounds of the heart, like the motions, are governed by the
same law in all warm blooded animals hitherto examined, and probably in
all kinds whatsoever, viz., that the first sound in all animals is longer and
obtuser, and the second sound shorter and sharper; that those sounds are,
as in the human heart, respectively systolic and diastolic j that their causa-
tion likewise follows the same law as those of man, the first sound being
mainly muscular, and the second exclusively valvular; likewise, that there
is the same causation and mutual relation of the cardiac and arterial pulsa-
tions.
JOHN CLENDINNING,
M. D. Oxon. and Edin., Fellow of the Roy. Col. of Physicians, &c. &c.
P.]
CONCLUSIONS FROM THE WHOLE OF THE EXPERIMENTS
ON THE SOUNDS.
CONCLUSIONS ON THE FIRST SOUND.
I shall not notice those theories which ascribe the first sound,
1st. To the collision of the particles of the blood against each
other and against the walls, in the interior of the heart (formerly-
broached by myself, but discarded in 1832).
2d. To the collision of the opposite interior surfaces of the ven-
tricles at the conclusion of their systole — both these theories having
been sufficiently disproved.
The theory of M. Magendie is. that the first sound is occasioned
by the collision of the heart against the ribs during its systole,
and the second, by its collision against the sternum during the
diastole. This theory is completely refuted, 1st, by my two origi-
nal series of experiments on the ass in 1830 (see p. 39), proving
that the sounds were perfect when the sternum and ribs were re-
moved : 2d, by my foregoing experiments on the sounds, Obs. 11,
in. which cc both sounds were distinctly heard through the lung
interposed between the heart and the end of the stethoscope5' — an
observation which I made specifically to refute M. Magendie, and
which was subsequently verified by the London Committee of the
British Association : 3d, it is refuted by hydro-pericardium ; as the
sounds are perfect though the interposed fluid prevents the heart
from impinging against the walls of the chest. This theory, I
should have dismissed more summarily, but that I perceive it has
been partially admitted by the London Committee of the British
Association, and by one of its members in a separate publication.
" An extrinsic or subsidiary sound,'' say the committee, "which,
in a variety of circumstances, contributes largely to the first sound,
arises from the impulse of the heart against the parietes chiefly of
the thorax;" and Dr. W , in his separate publication, says, "I
am disposed to admit that, in violent action of the organ, its more
sudden and abrupt strokes against the chest do cause a sound,
72 HOPE ON DISEASES OF THE HEART.
which constitutes the loud termination of the first sound in these
cases, and which seems nearer the ear, and more like a knock, than
what is heard in the ordinary action of the heart. In common pul-
sations, the apex of the organ is drawn upwards and forwards at
each systole, and sliding obliquely on the smooth pericardium, does
not impel against the ribs with sufficient abruptness to cause sound.
But in quicker and more violent pulses, the abruptness of the mo-
tion, and the force of the blow against the side of the chest, are
such as can scarcely fail to produce sound." (On Diseases of the
Chest, p. 178.)
These conclusions are precipitate. They proceed on an assump-
tion which is doubtful at least, if not absolutely erroneous : namely,
that the heart "impinges upon" (committee), or gives a "blow
against" (Dr. W ) the chest. Now, as has indeed been well
remarked by Mr. Bryan (Lancet, vol. xxix. p. 501), the heart is
held in contact with the walls of the chest by a force of fifteen
pounds to each square inch : if held in contact, it cannot impinge
or strike a blow : it can merely heave the chest, and such heaving,
however sudden or powerful, cannot produce sound. The com-
mittee rest on the fact that " leaning" to the left or forwards gave
additional force to the impulse and loudness to the sound; while
inclination of the body, such as to cause the heart to gravitate
away from the ribs, diminished at once the "sound and impulse."
But in both these positions, the heart is still in contact with the
walls of the chest, as is proved to demonstration by the continuance
of dulness on percussion^ — impaired indeed by leaning backwards,
but increased by leaning forwards. If, therefore, the heart is more
decidedly and positively in constant contact with the chest on lean-
ing forward, that is precisely the time when the increase of sound
observed by the committee ought not to be referable to the organs
" impinging" or " striking a blow" against the chest. This argu-
ment alone is conclusive against the doctrine in question; but as
the committee attaches much weight to the following experiment,
it may be desirable to point out its inconclusiveness.
"When a small opening," say they, "was made in the. carti-
lages opposite to the heart, the heart during systole was felt, both
outside and inside the chest, to press with force against the sternum
and cartilages." But here, if air was not admitted, and the heart
was kept in contact with the walls by atmospheric pressure, the
observation proves nothing to the point ; as it proves, not a blow,
but merely " pressure with force against the sternum" — which pres-
sure is insufficient to produce sound. But if air was admitted, the
observation still proves nothing; as the air, by causing collapse of
the lung, created any interval that existed between the heart and
the walls of the chest.
But though it is thus proved that the first sound does not receive
an augmentation from the heart impinging against the walls of the
chest (a conclusion to which I may here state that the Dublin
Committee of the British Association also came, in 1835) ; yet it
EXPERIMENTAL RESEARCHES. 73
does occasionally receive an augmentation from another cause,
the nature and circumstances of which have been overlooked, not
only by the committee, but, I believe, by every other writer up to
the present time ; and this same cause is the source of the metallic
cliquetis or tinnitus of Laennec, the true explanation of which, for
the same reason, has never been given. The cause alluded to is
simply this: the heart in gliding forwards and upwards during its
systole, strikes with its apex against the inferior margin of the
fifth rib, and thus creates an accidental sound, attended with cliquetis
when the blow is smart. It may be prevented at pleasure by press-
ing the edge of the stethoscope or anything else into the intercostal
space, by which that space is put, internally, on the same plane as
the rib, over which the heart then glides without catching. I have
never found the sound to occur in any but the meagre ; because,
in the well-conditioned, the intercostal spaces are full and resistent,
and, consequently, the edge of the rib is not exposed. It is not
necessary here to dwell on this phenomenon,1 but I may remark
that I have for many years noticed the first sound to be double in
some patients. The cause is, that the blow of the heart against
the edge of the rib is a little later than the first sound. As the
costal sound is accidental, it cannot be considered as constituting a
part of the normal first sound of the heart.
The necessity for an augment from extrinsic sources experienced
by the London Committee, perhaps originated in a difficulty under
which the advocates of mere bruit musculaire as the cause of the
first sound, found themselves : namely, that this sound, during pal-
pitation, is in some instances of such extraordinary intensity, that
it would do violence to all analogy to suppose it produced solely by
bruit musculaire. The sounds of muscular and valvular extension,
as will presently appear, adequately account for this intensity, and
supercede the necessity of resorting to any extrinsic cause.
I now proceed to notice what the foregoing experiments, as well
as pathological observations, lead me to regard as the exclusive
causes of the first sound : namely,
1st. The sound of muscular extension.
2d. " Bruit musculaire on rotaloire'1 — the dull, rumbling sound
of muscular contraction.
3d. The sound of valvular extension, the most important of all.
I place the causes in the above order, not from their relative im-
portance, but as the most convenient for discussion.
First Sound, how far caused by Muscular Extension.
By the term "sound of muscular extension," which I have used
to avoid circumlocutions, I mean a loud, smart sound produced by
the abstract act of sudden, jerking extension of the already braced
muscular walls, at the moment when the auricular valves close ;
in the same way that, when the valve of a pair of bellows closes,
1 See case of Carrington, Allan, &c.
74 HOPE ON DISEASES OF THE HEART.
its leather is put on the stretch, and, if not rigid, produces sound.1
Further, by the sound of muscular extension I mean a phenomenon
essentially different, in my opinion, from bruit musculaire ; since
the extension sound may be produced even in a dead muscle, and
may attain a high degree of loudness and smartness; whereas bruit
musculaire can only be produced in a living muscle, and is never
more than dull and subdued.
The existence of the sound of extension appears to me to rest on
strong1 grounds, and the London Committee of the British Associa-
tion, after repeating my experiments, are of the same opinion ; for
they say, " the facts relating directly to muscular tension, as a
possible cause of the first sound, are few but striking, and in their
judgment decisive."
The grounds are as follow : In Obs. 5 of my Experiments, it
was found that at each systole, the sudden tension of the ventricles
was such as to produce an abrupt shock to the finger placed
on any part of them, with which shock the first sound exactly
coincided. This phenomenon, pointed out by myself, and which
awakened in me the first idea of the sound of muscular extension
in contradistinction to bruit musculaire, made a forcible impression
on all present; and it was remarked that the sense of touch con-
veyed an identical idea with the sense of the hearing, for the sound
was as smart, loud and clear as the shock was abrupt. Again,
Obs. 23. The impulse from lateral expansion was greatest at the
margins of the auricular orifices, there throwing the finger out
with a violent jerk. Again, the committee say, " at each systole,
while the heart acted vigorously, the ventricle felt to the finger as
hard as cartilage" (Exp. 4) ; and, " the tension and hardness of
the ventricles during their systole, were very remarkable."- (Exp.
14). Further, the Dublin Committee, August 1835, say, "the
ventricles, with a rapid motion, assumed a somewhat globular
form in their middle part," and u during their continuance in this
state, they were hard to the touch, and, if grasped by the hand at
the commencement of the movement, they communicated a shock
or impulse, and separated the fingers" (Exp. 1). Under these cir-
cumstances, in all the observations, the first sound was perfectly
loud and distinct, as described in my Observations 1 and 10.
But when the circumstances were altered, namely, when the
resistance of the valves was removed, and the sudden shock or
1 Dr. C.Williams has remarked on my sound of extension, that "not
aware of the physical cause of muscular sound, he (Dr. Hope) has called
its abrupt commencement a sound of extension, which term, applied to con-
tracting muscle, is obviously contradictory and erroneous. The cause of
sound is resisted motion ; and the strongest and quickest motion, most ab-
ruptly and forcibly resisted, will give the loudest sound." (Med. Gaz. vol.
xvi. p. 820.) This is a mere verbal criticism. The fact is that resisted
muscular contraction is muscular extension, and this is all that I contend for.
"Who will deny that muscular contraction is resisted when the auricular
valves close? That not only tension, but extension is occasioned at the
moment of this resistance, I shall presently show.
EXPERIMENTAL RESEARCHES. 75
jerk of muscular extension thus prevented, the first sound was dull
and obscure, like the muscular sound which may be imitated by
the hand. This was exemplified in Obs. 7, " when an incision
was made into the left auricle, and a scalpel passed into the ven-
tricle, so as partly to destroy the mitral valve, and allow the free
escape of the blood ;" in Obs. 8, when " the right auricle was com-
pletely cut open ;" in Obs. 9. when "the finger was introduced into
the left ventricle, and made by pressure to prevent the influx of
blood into the right;1' and in Obs. 19, when "the arteries were cut
open." In all these cases, the first sound " was not so clear and
smart as when the ventricles contracted on their blood ;" it " was
obscurely audible." All this is admitted, with his usual incon-
sistency, by Dr. C. VV , a commentator on my experiments, and
an advocate of the exclusive muscular theory. He says the sound
presented "the duller and more obscure character of common mus-
cular sounds." (Med. Gaz. Vol. XVI. p. 820.) The London Com-
mittee, repeating the same experiments, say "the first sound was
still distinctly heard by all, but xoeaW (Exp. 7); yet they have
overlooked this weakness in their conclusions ; for they incon-
sistently say, " The -unvarying and uniform character of the sys-
tolic sound, however diversified the circumstances in which the
heart was placed, furnishes a strong argument in favour of its
intrinsic nature."
Such are the grounds on which the sound of muscular extension
appears to me to rest. But it may be objected that the sound was
occasioned, not by muscular but by valvular extension. This
argument is fair, and in fact it is difficult to say precisely to what
extent the valves do take part in the production of the sound. Yet
I believe that they do not produce it entirely, because the first
sound of the heart during palpitation is, in some instances, (and
here I do not allude to the accidental costal sound and metallic
cliquetis described above at p. 73,) of such extraordinary intensity,
that it would do violence to all analogy to suppose it produced by
extension of the auricular valves alone; and further, the loud
sound of palpitation is of a more blunt character than the valvular
click, such as I shall presently describe it as produced by the auri-
cular valves.
First Sound, how far caused by Bruit Musmlaire.
This term applies, in my opinion, to the sound, such as we
heard it whenever valvular and muscular extension were removed
by destroying the auricular valves or evacuating; the blood out of
the ventricles: namely, a dull, obscure sound (Obs. 9. 19), like the
muscular sound which may be imitated by the hand, or, to use Dr.
W s; expression, presenting the "duller and more subdued
character of common muscular sounds." This bruit musculaire
may possibly augment the intensity of the sound, and also impart
to it a dull or blunt character. It likewise contributes the well-
known prolongation, which so forcibly struck the Dublin Com-
76 HOPE ON DISEASES OF THE HEART.
mittee, as to lead them to conclude that " the cause of the first
sound is one which begins and ends with the ventricular systole,
and is in constant operation during the continuance of that systole."
(Report, August 11, 1835.) It will presently be shown, however,
that the first sound is not always prolonged: but that it is some-
times a mere click, and that this is probably in consequence of the
absence of bruit musculaire.
First Sounds how far caused by extension of the Auricular Valves.
Under the word " valves," I include the chordae tendineae, — fine
chords, equally calculated to produce sound as the membranous
expansions of the valves.
I have stated above that it is difficult to separate the valvular
from the muscular sound of extension ; because, being synchronous,
they are, as it were, incorporated together. The reality, however,
of the sound of valvular extension appears to me to rest on the
strongest possible presumptive evidence. In Obs. 22, " the first
sound was loudest over the parts of the ventricles nearest to the
auricular valves." I do not wish, however, to attach too much
weight to this observation. Again, we have seen that the ventri-
cles, in their systole, attain a hardness like that of " cartilage :" add
to this Obs. 23 ; " the impulse from lateral expansion was greatest
at the margins of the auricular orifices, there throwing the finger
out with a violent jerk." Now, the margins of the auricular orifices,
into which the valves are inserted, could not be jerked out with a
power that renders the ventricles as hard as cartilage, without sud-
denly putting the valves and chordae tendineae on the full stretch.
No one, I think, who carefully examines the anatomy of the auri-
cular valves, will doubt this. Nay, it seems to have been actually
felt by the London Committee. " On inverting the auricles again,
say they, the chordae tendineae of the mitral valve alone, were felt
to become tense in systole and lax in diastole." (Exp. 12.) Also,
" the finger was felt to be gently embraced and pushed, as if by a
membrane distended with blood." Sound, therefore, must neces-
sarily be the result of this violent valvular extension ; for it has
been proved by the foregoing experiments that sound positively is
produced by smaller membranes, — the semilunar valves, acted
upon with certainly inferior force, namely, that of the aortic column
of blood.
Again, when valvular extension was prevented by holding the
mitral valve open with a bent wire, as in Obs. 26, '-this greatly
diminished the first sound ;" and whenever the auricular valves were
destroyed, or the blood evacuated out of the ventricles, the sound
became dull and obscure.
This experimental evidence is corroborated- by pathological.
There is a considerable class of cases — some of valvular disease,
others of dilatation with attenuation, others again of mere soften-
ing,— in which the ventricles contract three, four, or more times
for each pulse felt at the wrist. Now, these intermediate contrac-
EXPERIMENTAL RESEARCHES. 77
tions, though so feeble as to produce little or no pulse, produce a
sound, and that sound is as brief, smart and clear — as pure a click,
as is produced even by the semilunar valves. I believe, therefore,
that it is occasioned solely by the extension of the auricular valves
and chordae tendineoe, for the production of which extension the
feeble ventricular contractions are sufficient, though insufficient to
produce either the sound of muscular extension or bruit muscul aire.
The same argument applies, though in a less degree, to hearts
with naturally thin walls, in which the two sounds approximate
in quality (Laennec:) and to dilatation with attenuation, in which
they become absolutely identical. In both these cases, the feebleness
of the ventricular contraction is evinced by the deficiency or absence
of impulse; yet the first sound is a well-marked click. I put it as a
question whether the first sound of the right ventricle is not, for the
same reasons, smarter than that of the left. It is bold to be too con-
fident on this point, as Laennec pronounced the sound of the two
sides to be "similar and equal;" yet reiterated observations incline
me to believe that the question which I have propounded, will
eventually be answered in the affirmative. Bouillaud thinks the
two sounds clearer at the base, of the sternum than between the car-
tilages of the fifth and sixth left ribs. (Traite I. 106.)
Further, the reality of the sound of valvular extension is corro-
borated by the inability of the advocates of the exclusive muscular
theory to rid themselves of the valvular sound, without direct con-
tradiction. Thus Dr. W , in one of his deductions from my
experiments, says : — " That the first sound is produced by the mus-
cular contraction itself, may be considered as proved by Obs. 8 and
9, in which every other possible source of sound was excluded, and
the first sound still accompanied the systolic action of the ventricles."'
(On Diseases of the Chest, p. 175.) Also : " That the first sound
is not dependent on closing of the auriculo-vcntricular valves, is
evident from five observations, in which the closure of these valves
was partially or completely prevented, yet the first sound continu-
ed." (Med. Gaz. Sept. 9, 1835.) These deductions are, 1st, not
only inconclusive, but actually opposed to Dr. W — — 's theory; be-
cause the sounds, though not annihilated, were always modified —
rendered dull, by disabling the valves: 2d, they are directly con-
tradicted in the next page by Dr. W himself; namely, "pro-
bably, in common pulsations, the ventricles do not attain the degree
of tension which is sonorous, until the closing of the auricular
valves; this closure, as the commencement of the resistance, brings
at once to its acme the muscular tension, which continues until the
contents of the ventricles are sufficiently expelled. This accounts
for the sudden or flapping commencement often perceptible in the
first sound, and it suggests how the due action of the auricular
valves generally contributes to its clearness. The auricular
valves, the chordce tendinece, the coiamnai carneai, and internal
fibres of the ventricles, if they attain the same degree of tension as
the exterior of the ventricles, may have an equal share in the pro-
78 HOPE ON DISEASES OF THE HEART.
duction of the first sound" (On Diseases of the Chest, p. 177.)
No advocate of the valvular theory contends for more.
The London Committee of the British Association, of which Dr.
W was a member, conclude " that valvular action is not a
cause of the first sound," because that sound continued, though the
action of the valves was prevented. But this conclusion is illogi-
cal, because, as already stated, the first sound was always modified
by interfering with the valves. Their argument, No. 2, " that the
action of the mitral valve, as felt by the finger, was of too gradual
and feeble a kind to be capable of producing sound," is contradicted
by another observation of their own which they seem "to have inad-
vertently overlooked; viz. "that the chordae tendineae of the mitral
valve alone were felt to become tense in systole." (Exp. 12.) The
committee endeavour to fortify their opinion by referring to the
heart of the domestic cock, in which there "is no tricuspid valve
resembling that of men, but the valvular office is discharged by
laminar extensions of the substance of the parietes of the ventricle,
which meet in the middle, so as during the systole to cover the
auriculo-ventricular orifice :" — yet in this animal M. Bouillaud
heard both sounds of the heart. This argument is without weight;
for if the valve consists of laminae at all, those laminae, whatever
their configuration, would produce sound when violently and sud-
denly extended.
The committee further endeavour to defend their exclusion of
valvular sound, by the following experiment, tending to show that
muscular contraction alone is adequate to the production of the first
sound. (Exp. 2.) "From the abdominal muscular contractions,
sounds of a systolic character in all respects, and as loud as, or
louder than, those of the heart, were with facility obtained. The
sounds were produced by sudden expiatory efforts made with force
and with the mouth closed, and were obtained with the flexible ear-
tube from various parts of the parietes. At the time the sound was
heard, the muscle under observation always felt to the finger tense
and hard ; but the sound ceased at the moment that the fibres had
attained their maximum of tightness and hardness^ and was not
renewed except by a repetition of the contractile efforts after previ-
ous relaxation."
I repeated this experiment, and found that the sound was owing,
not to the muscular contraction at all, but to a trifling adventitious
circumstance rather amusingly overlooked by the committee.
Making use of a flexible stethoscope, with a thin ivory extremity,
such as I had seen used by the reporter of the committee, — in
short, a common flexible ear-trumpet, I found that the "systolic"
sound was produced to admiration on some applications of the ivory
cup, but not at all on others. On carefully scrutinising the cause
of this remarkable difference, I found that the "sound was produced
by nothing more than the skin being dfawn out of universal con-
tact with the edge of the cup by the sudden retractile tension of the
abdominal muscles ; whence air was admitted and the sound gene-
EXPERIMENTAL RESEARCHES. 79
rated on the same principle as when a cupping-glass is removed:
for, in fact, the softness of the abdominal integuments, by causing
them to rise into the cup, creates a slight degree of vacuum. Ac-
cordingly, I found that when the cup was applied and then sud-
denly lifted off, without any motion whatever of the muscles of the
abdomen, the "systolic*' sound was still produced as perfectly as
ever. This experiment, therefore, which the London Committee
have placed, as if triumphantly, in the van of their report, is a mere
mistake.
The Dublin Committee of the British Association for 1835, con-
clude (No. 4) " That the cause of the first sound is one which
begins and ends with the ventricular systole, and is in constant
operation during the continuance of that systole." This may be
controverted by a denial that the fact is universally true. The
first sound, in hearts naturally thin or morbidly dilated, may, as
already explained, be as brief as the second. This fact supersedes
their next conclusion, No. 5, viz. "That it does not depend on the
closing of the auriculo-ventricular valves, at the commencement of
the systole, because such movement of the valves takes place only
at the commencement of the systole, and is of much shorter duration
than the systole."
I have now offered experimental evidence to prove that the
closure of the auricular valves causes sound: I have shown that
the advocates of the purely muscular theory of the first sound ad-
mit the valvular sound indirectly though they deny it directly :
finally, I have demonstrated that muscular sound alone is totally
insufficient to account for the first sound when it possesses a short,
clicking character like the second.
My conclusions respecting the causes of the first sound may
therefore be summed up in the following terms : —
The first sound is compound, viz. consisting, 1st. of valvular
sound : 2d, of the sound of extension — a loud smart sound, pro-
duced by the abstract act of sudden, jerking extension of the braced
muscular walls ; 3d, a prolongation, and possibly an augmentation,
by bruit musculaire.
Now these conclusions are identical with those which I published
in March 1835 (see the Appendix). We next proceed to the second
sound.
CONCLUSIONS ON THE SECOND SOUND.
As my experimental evidence amounts to demonstration, that
this sound is produced by the closure of the sigmoid valves exclu-
sively, I may here be brief.
The evidence is, 1st, that compression of the arterial orifices
with the fingers, so as to prevent the reflux of the blood on the
semilunar valves, invariably annihilated the second sound (Obs. 3
and 14, and the same repeated by the committees).
2d. Hooking up a semilunar valve in one artery, invariably di-
minished the second sound ; and doing the same simultaneously in
80 HOPE ON DISEASES OF THE HEART.
both arteries, invariably annihilated it, a murmur from regurgita-
tion being produced in its stead. (Obs. 15, 16, 17, and 18, and the
same repeated by the committees.)
3d. The second sound was loudest on the sigmoid valves, and
thence for two or three inches up the aorta. The conclusions
may be summed up in the following terms: —
The second sound is produced by the sudden expansion of the
semilunar valves, resulting from the recoil upon them of the
columns of blood in the aorta and pulmonary artery.
CONCLUSIONS ON MURMURS ARTIFICIALLY PRODUCED IN THE
FOREGOING EXPERIMENTS.
1st. Compression, however slight, of the aorta or pulmonary
artery produced a murmur and thrill with the ventricular systole.
2d. Hooking up a valve of one or both arteries, or perforating
a valve, produced a long sighing murmur from regurgitation. (Obs.
15 to 18, and 25.)
3d. Passing a bent wire through the walls of the left auricle,
so as to hold open the mitral valve, produced a very loud murmur
from regurgitation, attended with a strong thrill. (Obs. 26.)
4th. This wire did not occasion a murmur when the blood ivas
passing from the auricle into the ventricle, either during- the auri-
cular contraction preceding the ventricular systole, or during the
ventricular diastole. Nor was a murmur created at these times in
the case of Christian Anderson, though the mitral valve was con-
tracted to the size of the little finger, and the tricuspid to that of
the middle finger. I have met with several similar cases, and
therefore entertain doubts whether Laennec was correct in stating
that a murmur was occasioned by contraction of the auricular
valves, during the influx of blood from the auricles : still, I do not
absolutely deny this, but I feel assured that the murmur, if it exist
at all, is invariably very feeble ; and I have reason to know that
the loud murmur usually ascribed to this source, proceeds from
regurgitation through the semilunar valves.
ERRONEOUS OR DEFECTIVE THEORIES OF THE SOUNDS OF THE
HEART.
According to M. Raciborski, the muscular "is the Eldest theory
of the sounds, being the one which appears in the works of Galen,
Harvey, Senac, Haller, Bichat, and especially Corvisart, who all
ascribed the sounds to the successive shortening of the muscular
fibres. Laennec embraced the received opinion, which appeared
to him sanctioned by the experiments of Wollaston and Erman on
bruit musculaire. He thought that the first sound depended on the
contraction of the ventricular fibres, and the second on that of the
auricular ; and when Dr. Barry had demonstrated that the auricles
EXPERIMENTAL RESEARCHES. 81
were almost motionless and in a state of permanent plenitude,
Laennec had recourse to the contraction of the appendices of the
auricles to account for the second sound" (Raciborski. du Diag-
nostic, p. 760). Laennec's theory of the first sound is defective
because it overlooks the valvular sound : his theory of the second
is wholly incorrect because the auricles contract before the ventri-
cles, because the sound continues when the auricles are motion-
less (my Exp. p. 47), and because it is demonstrated above that
the closure of the semilunar valves is the sole cause of the second
sound.
Dr. C. J. B. Williams espoused the muscular theory in his
book in 1828. In his second edition he says of the first sound,
"In the former edition, I ventured to class it among the muscular
sounds which Dr. Wollaston first noticed to occur in all cases of
rapid muscular contraction. A good example of it may be obtained
on applying a stethoscope to the neck of a person who holds his
head back towards the opposite side, and then throws the platysma
myoides into contraction." (Rational Exposit. Appendix, p. 199.)
I shall hereafter show that this is nothing more than a murmur in
the jugular veins (see Venous Murmur); yet it unequivocally proves
what was Dr. Williams's type of a. muscular sound. After witness-
ing my experiments, however, in Nov. 1S34, and Feb. 1835, he
inconsistently disclaims the type to be his own, for he says " Dr.
Hope seems to have taken the dull, rumbling sound described by
Dr. Wollaston as the type of muscular sound." In short, after my
experiments had disclosed the existence of a sound of muscular
extension or tension, Dr. Williams adopted a new type of bruit
musculaire, but forgot his old one. I have shown that this exclu-
sively muscular theory of the first sound is defective by excluding
valvular sound. Dr. Williams's theory of the second sound up to
the time when he witnessed my experiments, was, " It is either
seated in the parietes of the ventricles rendered momentarily tense
by the sudden influx of the blood, or occasioned by the motions of
the fluid itself during the diastole." (Rat. Exposit. second edit. Ap-
pendix.) Incorrect, because my experiments demonstrated that
the closure of the semilunar valves was the sole cause of the second
sound.
Mr. Turner. Second sound, caused by collapse of the heart
on the pericardium during the ventricular diastole. Incorrect,
because the sound continues though the pericardium be removed.
Dr. Corrigan. First sound and impulse, caused by the rush of
blood into the ventricles, occasioned by the auricular contraction.
Incorrect, because the first sound and the impulse continue perfect
while the auricles are motionless (my Exp. p. 47). Second sound,
caused by collision of the internal surfaces of the ventricle, at the
end of the ventricular systole, which systole he supposes to be in-
stantaneous. Incorrect, because fully proved that the ventricular
systole, the impulse and the pulse of arteries near the heart, do not
9 — a 6 hope
82
HOPE ON DISEASES OF THE HEART.
coincide with the second sound, but precede it by a very consider-
able interval, (my Exp. p. 41 and 44.)
M. Pigeaux. First sound, by the rush of blood into the ven-
tricles during their diastole. Identical with Dr. Corrigan's, and
incorrect for the same reasons. Second sound, by the collision of
the blood against the walls of the aorta and pulmonary artery,
during the ventricular systole. Incorrect, because proved that the
second sound occurs at a considerable interval after the impulse
and pulse in arteries near the heart — consequently, after the ven-
tricular systole. Also disproved by the second sound being anni-
hilated whenever the semilunar valves are disabled. (Exps. on the
Sounds, p. 54. Obs. 3, 14 to 18.)
M. Marc tfEspine. First sound, the pure simple effect of the
ventricular systole. Incorrect, as it excludes the sound of the
auricular valves. Second sound, the pure simple effect of the ven-
tricular diastole. Incorrect, because proved that the semilunar
valves are the sole cause.
Dr. Billing, subsequently M. Rouanet, (who derived his idea
from Dr. Carswell) and simultaneously Mr. Bryan. First sound,
by closure of the mitral and tricuspid valves during the ventricular
systole. Imperfect, as it wholly excludes muscular sound. Mr.
Bryan, however, recognised a sound from muscular tension in one
of his papers in 1833, but in his subsequent strictures on the Dub-
lin Committee of August 1835, he ascribes the sound to valvular
closure alone. Second sound, by closure of the semilunar valves.
Correct.
M. Bouillaud adopts M. Rouanet's theory, but thinks that "the
smart recoil of the sigmoid valves against the walls of the aorta,
constitutes an element or condition of the first sound which ought
not to be neglected ;" he thinks also that the recoil of the auricular
valves against the walls of the ventricles may contribute to the
second sound. These additions are superfluous, if not incorrect.
Mr. H. Carlile. First sound, produced by the rush of blood
into the arteries during the ventricular systole. Incorrect, because
the sound continues though the orifices of the arteries be obliterated
by compression. Second sound, by closure of the semilunar valves.
Correct.
M. Magendie. First sound, produced by the collision of the
apex of the heart against the ribs during the systole ; and the
second sound by the collision of its anterior surface against the
sternum during the diastole. Incorrect, because both sounds re-
main perfect when the sternum and ribs are removed.
[M. Beau. First sound, caused by the blood rushing from the auricles
into the ventricles, and impinging upon the surface of the heart opposite the
auriculo-ventricular orifices. Identical with the theory of Dr. Corrigan, and
incorrect for the same reasons. Second sound, caused by the blood from
the veins striking upon the internal parietes of the auricles. Incorrect,
because all the experiments cited prove that the second sound is caused by
the closure of the semilunar valves of the aorta, and those of the pulmonary
artery. — P.]
PHYSIOLOGICAL PHENOMENA. 83
CHAPTER III.
PHYSIOLOGICAL PHENOMENA OF THE HEART'S ACTION AND
According to the data supplied by the foregoing experiments and
researches, and by the cases appended to this work, the physiolo-
gical phenomena of the heart's action appear to be as follows: —
I. The 'phenomena of the heart's action in the order of their
occurrence. — The first motion of the heart which interrupts the
interval of repose, is the auricular systole. It is a slight1 and
very brief contractile movement, more considerable in the auricular
appendix than elsewhere, and propagated with a rapid vermicular
motion, towards the ventricle, in the systole of which it termi-
nates rather by continuity of action, than by two successive move-
ments.2
The auricular systole is attended by a slight intrinsic sound, which is
absorbed in, or masked by that of the louder sound of the ventricular con-
traction. [Pennock's and Moore's experiments and the report of London
Committee for 1839— 40.]— P.
1 I suspect that during palpitation it becomes much more considerable ; for,
in subsequent experiments on young asses poisoned with woorara, which
less impairs the action of the heart, I found the auricular contractions very
full and active whenever the pulse rose 20 or 30 beats above the natural
standard ; but when the palpitation subsided, the contractions again became
slight.
2 It has been supposed by Laennec, who is supported by Bouillaud, that
the auricular systole may produce an impulse. As I believe this opinion to
be erroneous, I shall briefly present and comment upon the data on which
it is founded. ': If the contraction of the auricles, "says Laennec,*' produces,
in some rare cases, a phenomenon analogous to the impulse of the ventri-
cles during their systole, it is easy to distinguish the one from the other. In
fact, when the auricular systole is accompanied with a sensible movement,
this movement is much more deep : it seems even that the heart withdraws
itself from the ear. ... In all cases, it is very slightly marked in compa-
rison of the sensation of heaving produced by the contraction of the ventri-
cles when their walls are of a good thickness."
Now, as it has been shown in the foregoing experiments that the contrac-
tion of the auricle is a slight movement, and that it withdraws the auricular
appendices from the walls of the chest instead of causing them to advance
forward, — circumstances which render it impossible for the auricles to create
an impulse by impinging against those walls, I have no doubt that what M.
Laennec noticed, in the "rare cases," alluded to, was, the diastolic impulse
of the ventricles, a phenomenon to which attention was first drawn by the
writer as a sign of hypertrophy (see Impulse of Simple Hyp.); and I am
confirmed in this opinion by his expression that the heart, in giving this im-
pulse, "seems to withdraw itself from the ear.'' See also my Exp. p. 40.
M. Bouillaud, however, espouses Laennec's opinion. "If the systole of
the auricles," says he, " is not accompanied with an appreciable impulse in
the healthy state, it is not the same in certain cases of disease." After
quoting the above passage from Laennec, he proceeds, " Out of the exam-
ples which I could adduce in support of what has just been said, I shall
6*
84 HOPE ON DISEASES OF THE HEART.
The ventricular systole commences suddenly, and, at the mo-
ment when the auricular valves close, a strong lateral impulse is
felt — especially in the vicinity of the auricles, while the walls attain
an extreme degree of tense hardness : simultaneously, the apex is
tilted up and is drawn towards the base. The systole terminates
in the diastole, which is marked by the second sound. Synchro-
nous with the systole are, the first sound, the impulse of the apex
against the ribs, and, in vessels near the heart, the pulse ; but, in
vessels at some distance, as the radial, the pulse follows at a barely
appreciable interval.
The systole of the ventricles is followed by their diastole, during
which they return, by an instantaneous expansive movement sen-
sible to the touch and sight, to the same state (with respect to size,
shape, position, &c.) as during the previous interval of repose.
This movement or diastole is accompanied by the second sound,
by an influx of blood from the auricles, by a slight retractile motion
of these cavities most observable at their sinuses, and by a retroces-
sion of the apex of the heart from the walls of the chest.
Next succeeds-the interval of repose, during which the ventricle
remains at rest, in a state of fulness, though not distention, through
the whole period intervening between the second and the first
sounds; but the auricle remains at rest during the first portion
only of that period, the remainder being occupied by its next con-
traction, with which recommences the series of actions described.
The rhythm of the heart, that is, the duration of the several
parts of this series, which constitute what may be called a beat, is
much the same as described byLaennec: viz. 1. The ventricular
systole occupies half the time, or thereabouts, of a whole beat. Mr.
Bryan says a third only (see p. 44, note). 2. The ventricular
diastole occupies a fourth, or at most a third. 3. The interval of
ventricular repose occupies a fourth, or rather less, during the lat-
ter half of which the auricular systole takes place.
II. Causes^ mechanis?n, mid objects of the motions. Though
Haller accurately noticed the motions of the heart, he was unable
to account for the particular order of their occurrence. Hence he
choose the following. In a female affected with an enormous hypertrophy
of the heart with induration of the mitral valve, a movement of impulse was
distinctly seen to be communicated to the left supra-mammary region, to
about an inch below the clavicle (in the 2d and 3d intercostal spaces); the
finger placed on this part was repelled, as it were, by a very marked shock.
This movement, which could only be attributed to the systole of the dilated
and hypertrophous left auricle (for the ventricular beats were felt two inches
lower down) alternated with another which corresponded to the (auricular)
diastole. This double movement of undulation — of contraction and dilata-
tion— perfectly imitated that presented by the denuded heart." (Traite I.
149. 1S35.) As this chosen case was not attended with a post mortem ex-
amination, it does not prove M. Bouillaud's point. For my own part, I
have scarcely a doubt that the case was one of dilatation of the pulmonary
artery, which I have found to produce the precise symptoms described by
M. Bouillaud. (See Dilat. of Pulm. Artery.)
PHYSIOLOGICAL PHENOMENA. 85
says « The reason is a postulatum (postulatnr ratio) why, first, the
right and simultaneously the left auricle contract, while in the
mean time the ventricles rest relaxed ; why, a little after, the auri-
cles are relaxed, but the ventricles contract; and then, in a third
portion of time, the ventricles repose relaxed, but the auricles again
smartly contract." (De Motu Cordis; Lugduni Batavorum ; 1737,
p. 37.) The reasons required can now be assigned. The auri-
cles, which are always in a state of fulness though not distention,
arrive, from the progressive influx of blood during the first portion
of the ventricular repose, at the state of distention, by which they
are stimulated to contract. The object for the contraction at this
moment, is, to propel a small additional quantity of blood into the
ventricles, already full, for the purpose of bringing them from the
state of mere fulness to that of distention : — an object which could
not be accomplished without a contraction, as the blood could not
otherwise force its way into the ventricles against the resistance
offered by their elastic parietes. These cavities, then, being brought
to the state of distention, are thereby stimulated to contract. They
expel a greater or less proportion of their contents — the whole in
small animals, frogs for instance, — as is proved by the ventricles
becoming pale ; but in large animals, as the ass, they do not appear^
judging from the diminution of size, to expel the whole, though, as
the ventricular walls are opake, whether they do or not, does not
admit of demonstration. During the act of expulsion the apex is
tilted forwards and upwards and occasions the impulse against the
ribs. On the mechanism of this motion, a point hitherto much dis-
puted, it is necessary somewhat to enlarge.
When the heart of an animal, as a frog, rabbit, dog, turtle, &c.
is detached from the body before organic life is extinct, and placed
upon a table, it continues to act, and each contraction elevates the
apex. Hence it is unquestionable that the muscular fibres have an
inherent faculty of producing this action. The manner in which
the action is accomplished is very visible on inspection. During
the state of relaxation, the heart lies collapsed and flattened, with a
large extent of its under surface applied to the table ; on contract-
ing it starts up, and, assuming a more rounded form, is sustained
by a comparatively small point of contact. The apex is, conse-
quently, elevated, and the elevation is greater in consequence of
the base, from its superior weight, being the more fixed part. The
action is closely analogous in the living subject. Before describing
it, I shall advert for a moment to the anatomical disposition of the
parts of the heart.
In large animals, as the human species, the auricles, especially
the left, are attached to the posterior part of the base, and the aorta
and pulmonary artery spring from its anterior part. These ves-
sels are the fixed points towards which the fibres of the heart con-
tract during the ventricular systole, and their stability is increased
by the injection and distention which they undergo during the sys-
tole. The sinuses of the auricles being constantly full, even during
86 HOPE ON DISEASES OF THE HEART.
the contraction of the appendices, and regurgitation of their con-
tents into the veins being opposed by the elasticity of the venous
coats, by the pressure of the surrounding parts, by the capillary
vis-a-tergo, and by the atmospheric pressure, with a power exceed-
ing the weight of the ventricles, the auricles form an almost un-
yielding fulcrum beneath the ventricles during the systole of the
latter.
Such being the anatomical and physiological state of the parts,
during the ventricular systole the braced fibres, contracting to-
wards the aorta and pulmonary artery in front, draw the tense and
rounded body of the ventricles upon "the auricular sinuses behind.1
Consequently, the apex of the ventricles is tilted up ; and this
motion is performed with considerable velocity, because, if I may
be allowed the illustration, the apex is the long arm of the lever,
the auricles being the fulcrum, and the moving power at the aorta
and pulmonary artery. In proportion as the ventricles contract to
their extreme, the apex is not only retracted towards the base, but
thrown more and more forward by the auricular distention, advanc-
ing in the same progression to its extreme. Another circumstance
probably contributes to the elevation of the apex ; namely, the
retropulsion of the auricular valves: for, as these act on a column
of fluid which offers a resistance greater than the weight of the
heart, the action is reflected on the organ itself, and impels it for-
ward. I have seen the impulse of the heart prodigiously increased
by an aneurism of the aorta forming a solid fulcrum immediately
behind the heart: also by adhesion of the pericardium binding the
organ in front of the spine: by pleuritic effusion throwing it into
the same position : and Dr. Stokes says, by tubercular consolida-
tion of the lung behind the heart. All these causes act by afford-
ing a more unyielding fulcrum behind the organ than the healthy
lung, and they constitute pathological corroborations of the view of
the heart's impulse which I maintain.
The diastole appears to be occasioned by several concurrent
causes; viz. 1. That power of the muscle (whether elasticity or
something more is unimportant) by which it reverts from the state
of contraction to that of relaxation, and in virtue of which it exer-
cises a degree of suction. 2. The distention of the auricles, which
is greater at the moment of the diastole than at any other, as they
have been filling during a longer period — namely, that of the ven-
1 Mr. Bryan has shrewdly observed upon this that it " implies imperfection
in the mechanism of the heart; for if, when the ventricles contract, they
make pressure on the auricles, the ventricles must waste a portion of their
power in impeding the action of the auricles. (Lancet, vol. xxiv. p. 783.)
But it is stated above that the auricles contain a column of fluid which offers
a resistance greater than the weight of the heart — therefore the action of
the auricles would not be impeded by that "weight. It is not improbable
that the pressure of the ventricles during their systole operates as a salutary
check on the auricles, preventing them from becoming immoderately dis-
tended during the long period of the ventricular systole.
PHYSIOLOGICAL PHENOMENA, 87
tricular contraction or about half of a whole beat. 3. The weight
of the ventricles collapsing from their systole on the distended
auricles beneath them. 4. The width of the auriculo-ventricular
orifice, which allows the blood to shoot in without impediment. It
is manifest that as so many powerful causes conspire to effect the
influx of the blood, an auricular contraction at this time, and for
this purpose, as imagined by Laennec, would be superfluous. The
draught of blood from the auricles during the diastole, causes the
slight retraction of these cavities observable at that moment.
The object of the interval of repose, is, to afford rest to the organ,
and no arrangements could answer this object so completely as
those described. We see that the ventricles, by their diastole, are
brought to the state most favourable to their repose — that of natural
fulness without distention, and in this state they remain, to employ
an approximative calculation very nearly exact, one fourth of each
beat or six hours in twenty-four : but, if we admit that the diastole
also is a kind of repose to the ventricles, we must add another
fourth, making the whole period half a beat or twelve hours, which
is the period assigned by Laennec. (De l'Auscult. torn. ii. p. 408.)
Had the auricular systole succeeded the ventricular and imme-
diately brought the ventricles from the state of contraction to that
of distention, as supposed by Laennec, there could have been no
repose, as distention implies the exertion of the tonic power of a
muscle, which, as is well known to those who have to reduce dis-
located joints, is eminently productive of fatigue. Nor, indeed,
could any interval of action then have taken place ; for, admitting
distention to be the stimulus of the ventricles, their contraction
would have ensued instantly on their being brought into the state
of distention. We see, further, that according to the theory which
1 advocate, the auricles, by evacuating their contents into the ven-
tricles at twice instead of once, avoid the excessive distention at
which they must have arrived had the blood been accumulating in
them during three fourths of a beat. Although their systole occu-
pies only about one eighth of a beat, or half the time between the
second and first sounds, the whole of the remaining seven eighths
is not devoted to repose; for, during the greater part of this time,
the auricles are in a state of greater or less distention, which, as
above stated, is not repose. Under these circumstances it is too
hypothetical, if not impossible, to estimate by numerical calculation
the exact amount of the auricular repose, but analogy, counte-
nanced perhaps by a rude calculation, leads us to infer that it must
be about equal to the ventricular. Laennec estimates it at one half
more, or eighteen hours in twenty-four, but this he does on the
assumption that the auricular contraction occupies one fourth of a
beat, and without allowing for the fatigue occasioned by the state
of distention into which the auricles are brought during a portion
of the intervals between their contractions.
As M. Magendie has adopted a kind of alternate theory of the
heart's movements, which has been incautiously copied, on the
88 HOPE ON DISEASES OF THE HEART.
authority of so high a name, by the bulk of systematic writers, it
may be well to point out its inaccuracy. " If," says he, "the heart
of a living animal is denuded, we easily see that the auricles and
ventricles contract and dilate alternately. These movements are
so arranged, that the contraction of the auricles takes place simul-
taneously with the dilatation of the ventricles, and vice versa, that
the contraction of the ventricles coincides with the dilatation of
the auricles." (Quoted by Bouillaud, Traite I. p. 87.) The great
defect of this view is, that it leaves no interval of repose. It is
easy to see how M. Magendie has been misled, namely, by operating
on living animals ; for I have always found, that when the animal
unfortunately retained or regained the slightest degree of sensibi-
lity, the action of the heart was so violent, convulsive, and rapid,
as to present the appearance of alternate action described by M.
Magendie. In small animals, also, as rabbits, whose pulse beats
150 to 200 a minute, the same appearance is generally presented
even though they have been completely killed ; for the interval of
repose is too brief to be distinctly appreciated by the eye. Nay, in
asses poisoned by woorara, much the same appearance is presented
whenever the pulse is accelerated twenty or thirty beats above its
natural standard of forty or fifty, the contraction of the auricle then
becoming more active and extensive, and encroaching so much on
the interval of repose as to render it indistinct to an unpractised
eye. I am, therefore, inclined to think, that during palpitation or
naturally accelerated action, the period of repose actually is en-
croached upon. The muscle, indeed, can bear an occasional and
temporary encroachment of this kind with impunity; but when
palpitation is long continued, we know that it issues in hypertrophy,
or dilatation, or both.
The ocular deception under which M. Magendie has laboured is
corroborated by an appeal to physiological principles. Let us
enquire how the heart would act, on his alternate principle, in
large animals with a pulse of fifty, as in many human subjects, or
of forty or less, as in horses, &c; or let us take for illustration a
still more striking case of a gentleman, (whom I at present see in
common with several other practitioners,) with a pulse of twenty-
eight, without the slightest intermediate beat or sound of the heart.
The second sound follows the first almost as quickly as when
the pulse beats sixty or seventy : consequently there is a period of
repose of about a second and a quarter, as three quarters of a se-
cond suffice for an ordinary systole and diastole. What, then, on
M. Magendie's view, must be the state of the heart during this
second and a quarter of repose ? The ventricles must be in the state
of diastole, because this state follows the second sound. Now the ven-
tricular diastole, says Magendie, is synchronous with the auricular
systole : consequently, the auricles, after their systole, must remain
in the state of spasmodic constriction for the period of a second and
a quarter waiting for the next contraction of the ventricles, which
are unexcited by the stimulus of distention ! This is monstrous!
PHYSIOLOGICAL PHENOMENA. 89
Its physiological impossibility is palpable. How much more simple
and natural and beautiful to suppose that the relaxing ventricles
refill, without distending themselves, from the auricles, and that the
whole organ then remains id repose till the progressive venous in-
flux provokes the next auricular contraction ! How admirable the
arrangement by which the auricles tranquilly deliver their blood at
twice, instead of the single, violent, alternate delivery supposed by
the view of M. Magendie ! Fortunately, his high authority is op-
posed by that of Harvey and Haller, not to mention the experiments
of the writer, and the repetitions and confirmations of them by the
Dublin and London Committees of the British Association. M.
Bouillaud appears to follow Magendie (Traite de Bouillaud I. p.
136, 1835); and this error has betrayed him into several others
respecting physical signs. Dr. Bostock also follows Magendie, but
evidently from inadvertence ; for he applauds Haller's experiments,
which coincide with the writer's, and are opposed to the alternate
theory of Magendie.
III. The Causes and Mechanism of the Sounds. This subject
is so fully discussed in the last section (see Conclusions, p. 71) that
a brief summary will here be sufficient.
First sound. This is compound, consisting, first, of the click of
the auricular valves : secondly, of the sound of muscular extension
— a loud, smart sound, produced by the abstract act of sudden jerk-
ing extension of the braced muscular walls at the moment when
the auricular valves close: thirdly, of a prolongation, and possibly
an augmentation; by bruit musculaire^ i. e. the dull, rumbling
sound of ordinary muscular contraction.
The valvular click gives smartness and intensity to the com-
mencement of the first sound, and id feeble hearts, in which the
sound of extension and of bruit musculaire are absent, the click
alone is heard, causing the first sound to be identical in quality
with the second. This occurs, for instance, in dilatation with
attenuation. The sound of muscular extension superadds blunt-
ne'ss and loudness to the valvular click, and is probably a principal
cause of the extraordinary intensity of the first sound, often observed
in violent palpitation. It differs from the sound of costal percus-
sion with metallic cliquetis, which imparts a double character to
the first sound and only exists under the circumstances described
at p. 41. The bruit musculaire forms a gradually diminishing
prolongation of the sound to the end of the act of contraction: but
when the heart acts feebly, either from disease, or from mere tem-
porary exhaustion or faintness, the bruit musculaire may be par-
tially or wholly absent.
Second Sound. This results from the sudden expansion of the
semilunar valves, occasioned by the reflux upon them of the
columns of blood in the aorta and pulmonary artery during the
ventricular diastole.
The auricles do not contribute to the production of either of the
sounds ; as. in the experiments on the ass, they were heard in equal
90 HOPE ON DISEASES OF THE HEART.
perfection when the auricles were in a state of immobility. Nor
does the auricular contraction, in my opinion, produce any sound
whatever; for the movement during tranquil action of the heart,
in large animals at least, is too inconsiderable, to be capable of it.
Further, there are no circumstances of structure or resistance to
occasion valvular or muscular extension. Finally, no third sound
of the heart is ever heard. M. Bouillaud, indeed, has pronounced
this last assertion to be inaccurate ; and, in proof, he cites " cases of
disease of the heart in which he had heard, and caused a great
number of persons to hear, three, or even four, sounds instead of
two during a single rhythm." These supernumerary sounds he
ascribes to auricular contractions, but he labours under an entire
misapprehension. The truth is, that the sounds really result from
ventricular contractions, but contractions so feeble as not always to
produce a pulse perceptible at the wrist. The proof is, that, in
almost all such cases, the third and fourth sounds are every now
and then attended with a barely perceptible pulse, which inevitably
connects the sounds with ventricular contractions. Sometimes the
pulse can be felt in the carotid when it is imperceptible in the
radial. These cases are far from uncommon. I have notes of
twenty or thirty, and my limits alone prevent me from transcribing
several before me.
[The author is in error, when he asserts, that the auricular contraction
does not produce sound. In the experiments of Drs. Pennock and Moore, it
was first proved, that a sound does exist during the muscular contraction
of the auricle, " similar to that of the ventricles, but very short, more flap-
ping, resembling very nearly the first sound of the foetal heart." By the
London Committee of the British Association for the years 1839 — 40, this
fact has been fully verified. It is difficult to imagine, why theractive mus-
cular contraction of the auricle should be doubted. That muscular fibres of
some size exist, is sufficiently evident even upon cursory inspection of the
heart : why deny to such muscular structure, the contractile power possessed
by other muscles ? — P.]
The first sound is best heard at that part of the precordial region
where there is dulness on percussion from the heart being in con-
tact with the chest ; for the sound is best conducted to the surface
through a solid medium, without the intervention of the spongy,
ill conducting tissue of the lungs. The second sound is best heard
over the semilunar valves, viz. on the sternum, opposite to the inferior
margin of the third rib, and thence for about two inches upwards,
along the diverging courses of the aorta and pulmonary artery re-
spectively, the sound high up the aorta, proceeding mainly from
the aortic valves, and that high up the pulmonary artery being
mainly from the pulmonic. This subject is more fully developed
at p. 31. It has not been fully understood by other authors, nor
was it by the writer in the first edition of this work.1
1 The author of the Rational Exposit. has criticised that edition, but
seems to have forgotten that I supplied him with the criticisms. My recti-
fications were published previous to his criticisms in the appendix to the 2d
edit, of the present work.
PHYSIOLOGICAL PHENOMENA. 91
For an account of the extent over which the healthy sounds
are audible and the circumstances which occasion variations, the
reader is referred to Dilatation, sounds of; and also to Hypertro-
phy.
First principle of the heart's motion. After having studied all
the physiological phenomena of the heart's action, an ulterior ques-
tion naturally presents itself — what is the first principle, — the
primary spring, which gives motion to the great organ of the circu-
lation. As this is rather a question of physiological interest, than
one the determination of which is essential to the present sub-
ject, I shall merely glance at the existing opinions, and leave the
reader to prosecute the inquiry by referring to original sources of
information.
It is the persuasion of many distinguished physiologists, particu-
larly those of the French school, founded, as they conceive, on
experiment and observation, that the nerves of the heart constitute
its motive principle. But, as these nerves are derived from two
sources, — the cerebro-spinal, and the ganglionic systems, it was a
question which of the two were destined to impart the faculty of
motion. Le Gallois ascribed this faculty to the spinal nerves ; but
his conclusions were subverted by the researches of Lallemand,
who found that the heart beat in the fcetus though destitute of
spinal marrow; and by the experiments of Wilson Philip, Mayo,
Clift, and many others, who found that the action of the heart sur-
vived the destruction of the spinal marrow, and even the excision
of the organ out of the body. Hence it resulted that, while the
cerebro-spinal nerves or par vagum (according to the brilliant dis-
coveries of Sir Charles Bell and the recent extension of them under
the name of the excito-motory system discovered by Prochasca,)
connected the heart with the lungs, the stomach, the thoracic mus-
cles, the face, — with all the parts, in short, associated in the func-
tions of respiration and expression, and, in fact, with the whole
system ; the ganglionic nerves, or, in other words, the great sym-
pathetic, was the principle which imparted the faculty of motion.
Thus it was explained how the action of the heart was independent
of the will, while it was strongly under the empire of the passions
and of corporeal nervous sympathies.
Mr. Mayo, on the contrary, founding his opinion on a train of
profound and ingenious reasoning, partly developed in his work
on physiology, but which he has done me the favour to explain
more at length, entertains the belief that the motive principle of the
heart is an innate power independent of the nerves: and that, while
it is the natural state of voluntary muscles, both in the living
body and before the loss of irritability after death, to remain relaxed,
unless excited by special impressions; it is, on the other hand, the
natural state of the heart, an involuntary muscle, under the same
circumstances, to contract and dilate alternately for a time, in the
absence of external impressions. In the turtle, an extremely viva-
cious animal, the alternate actions continue for a very long period.
92 HOPE ON DISEASES OF THE HEART.
I have seen them last for upwards of an hour, though sections were
made both longitudinally and transversely into the cavity of the
ventricle. The motive principle, whatever it be, appears to be
more or less exhausted by each contraction ; for a puncture, made
immediately after the effort, does not cause a repetition of it ; but,
made at the interval of a {ew seconds, it produces the effect.1
Whether the motive principle be nervous, or an innate power, it
is sufficient for our present purpose that the organ replies to a
stimulus. This stimulus, in the natural state, is the blood ; and by
flowing into the heart in suitable quantities at definite intervals,
according to the principles above explained, it appears to maintain
the action of the organ in a state of regularity. Mr. Granger,
advocating the existence of the reflex function in the ganglions of
the great sympathetic, maintains the same view. " The heart,"
says he, " may be selected for the sake of illustration ; the blood
reaching the cavities of that organ makes an impression upon the
incident branches of the cardiac nerves (i. e. those which go to the
cardiac ganglion) ; this impression excites the power of the cardiac
ganglion, the influence of which being transmitted by the reflex
cardiac twigs (i. e. those going from the ganglion), causes the
muscular substance to contract." He adds in a note, " If the cardiac
nerves and ganglion are essential to the heart's action — and that
they are so, will, I feel confident, be ultimately established — their
action must be l excited' (by the blood stimulating the incident
branches); or otherwise we must allow that the ganglions can
spontaneously stimulate the muscular fibre, or, in other words, that
they are intelligent agents." (On the Spinal Cord> p. 142, 1837.)
CHAPTER IV.
SOUNDS.
SECTION I. — Modifications of the Motions and Sounds by Hypertrophy, and
Dilatation.
By Simple Hypertrophy, the impulse is increased and the sounds
are diminished. "The impulse," says Laennec, "is ordinarily
sufficiently strong to heave the head of the observer in a very
sensible manner, and sometimes it is so strong as to produce a
shock disagreeable to the ear. The greater the hypertrophy, the
more time that heaving- takes for its performance, and, when the
disease is carried to a high degree, we evidently perceive that it
[' Professor Dunglison's views essentially resemble those of Mr. Mayo.
Vide his work on " Human Physiology." — P.]
PATHOLOGICAL PHENOMENA. 93
takes place by a gradual progressioji ; it seems as if the heart
swelled and applied itself to the walls of the chest, at first by a
single point, then by its whole surface, and, in the next place, sud-
denly sunk back" (s'aifaisse.) In considerable hypertrophy, and
still more in hypertrophy with dilatation, this sinking back termi-
nates in a jog or shock, to which I called attention in the first
edition of this work, as a new sign of these affections, under the
name of back-stroke. The term diastolic impulse, however, is
more descriptive, and I shall therefore employ it.
The first sound, i. e. that attending the ventricular systole, is
duller and more prolonged than natural, in proportion as the
hypertrophy is more considerable; and, when this exists in an
extreme degree, the sound becomes nearly extinct, but never
according to my observation, wholly so, as stated by Laennec.
The second sound, i. e. that produced by the closure of the sigmoid
valves during the ventricular diastole, is weaker than natural:
Laennec says that in extreme cases it is scarcely perceptible ; but I
have always found it distinct when the stethoscope was placed accu-
rately about an inch or two higher up than the sigmoid valves.
The causes of these modifications are very intelligible. The
power of the impulse is increased in the direct ratio of the hyper-
trophy; and the movement is a progressive heaving, because the
hypertrophous ventricle, from being thick and unwieldy, contracts
slowly and with a gradual progression. For the same reason the
first sound is diminished, — is dull and stifled; because, as the
closure of the auricular valves is sluggish, it is attended with a less
jerk of extension both of the valves and chorda? tendineie and of
the ventricular walls. I think also that the sound is somewhat
deadened by the increased thickness of the ventricular walls
through which it has to be transmitted.
The second sound is also diminished, because the ventricular
diastole, no less than the systole, being performed more sluggishly,
the recoil of the blood on the sigmoid valves is less smart; and this
smartness is still farther diminished in hypertrophy with contrac-
tion, because the quantity of blood expelled by the ventricles is
insufficient adequately to distend the arteries.
[In Simple Hypertrophy, uncomplicated by disease, and free from valvular
lesion, the second sound remains undiminished. — P.]
By Simple Dilatation, and Dilatation with Attenuation, the
impulse is diminished, often to the extent of being imperceptible.
When perceptible, it is a sudden brief blow, which communicates a
shock or vibration to the thoracic walls, but has not power or dura-
tion to elevate them. The reason is, that, as a thin muscle has less
power, but greater facility and rapidity of motion, than a thick one,
the attenuated ventricles contract on their contents with greater
velocity than natural, but their action is more feeble: accordingly,
the impulse is diminished, and its power is sooner exhausted, —
whence the brevity of the shock. The apex, in other words, is
94 HOPE ON DISEASES OF THE HEART.
suddenly tilted forwards, and its force seems to be expended, as it
were, in the act.
The first sound in dilatation, becomes loud, brief, and clear, like
the second. This arises from the muscle, in consequence of its
thinness, contracting with increased facility and velocity, — whence
the extension of the auricular valves with their chordae tendineae,
and of the muscular walls themselves, is more sudden and smart.
The sound is not prolonged by bruit muscidaire, apparently in
consequence of the feebleness of the contraction. In dilatation
with attenuation, the first sound is so brief and often feeble a click,
that I believe it to be produced by valvular extension alone.1
The second sound is more or less increased, because the thin
ventricle, from having greater facility of movement, performs its
diastole, as well as its systole, with greater velocity ; whence the
recoil of the sigmoid valves is more sudden. In dilatation with
extreme debility of the organ, however, I have often found both
sounds weaker than natural, from the excessive feebleness of the
heart's action.
By Hypertrophy with Dilatation. The modifications occasioned
by this affection are compounds of those of hypertrophy and those
of dilatation. The contractions of the ventricles give a strong
impulse — " abrupt, dead (sec), violent blows, which strongly repel
the hand" (Laennec de PAuscult. torn. ii. p. 515): they partake, in
short, of the power of hypertrophy and the smartness of dilatation.
The first sound is increased, sometimes exceedingly, so as, accord-
ing to my observation, to be louder than in any other disease of the
heart. This is in consequence of the violence and velocity of the
valvular and muscular extension. The sound is prolonged by
bruit muscidaire. The second sound is increased to its maximum,
partly from the ventricular diastole being quick and vigorous, but
partly also from the tension of the arteries being increased by the
preternatural quantity of blood injected into them, whence the recoil
of the blood on the sigmoid valves is more violent and rapid.
Hypertrophy with dilatation is occasionally accompanied, espe-
cially during palpitation, with a soft and slight bellows-murmur,
an exposition of the cause of which I reserve for a future section
on Murmurs from Hypertrophy with Dilatation.
The impulse and sounds, in any affection of the heart, may
partially, and the impulse even totally, fail, when the organ, either
from its own debility, or an obstacle in the course of the circulation,
[' Dilatation with attenuation is generally attended by dilatation of the
auriculo-ventricular orifices, which renders the tri-cuspid and mitral valves
incapable of closing their respective orifices. In this case, although the first
sound may be extremely brief, the cause assigned by the author for its pro-
duction is unsatisfactory. The valvular extension atone not being sufficient
to produce the closure of the orifices, a regurgitant bellows murmur is pro-
duced instead of a " click." Under these circumstances, muscular contrac-
tion of the attenuated parietes must be assigned as the cause of the clear
sound. — P.]
PATHOLOGICAL PHENOMENA. 95
is gorged with an accumulation of blood which exceeds its propul-
sive power ; and also when the vital powers are reduced by any
cause whatever. This is not only indicated by pathology, but is
demonstrable on the stupified living animal ; for, if artificial respi-
ration be temporarily suspended, the diminution of sound and im-
pulse immediately takes place, and it may thus be produced and
removed at pleasure. The heart, during the intervals of inflation,
is seen in a gorged state, scarcely contracting or dilating. (See
Experiments, p. 23.)
[In the exposed heart of the living animal it has been seen, (Pennock and
Moore's Experiments,) that congestion of the right cavities takes place be-
fore that of the left, and that with this congestion, the sounds previously
observed at the valves of the pulmonary artery and over the parietes of the
right ventricle become extinct ; the second sound at the valves ceasing before
the systolic. In disease similar phenomena are observed, but the entire ces-
sation of the second sound is more frequently met with, than that of the
first.-P.]
SECTION II. — Murmurs produced by Valvular Disease.
By valvular disease the sounds acquire various morbid mur-
murs, as those of bellows, sawing, filing, rasping, whistling or a
perfect musical tone; and these sounds are valuable signs of val-
vular disease. I shall first notice the circumstances under which
they occur, and subsequently advert to the mechanism of their
formation, and explain the causes of their varieties. It will be
seen that they perfectly assimilate with, and substantiate the view
that I have taken of the motions and sounds of the heart.
The illustrious author of Auscultation was acquainted with two
circumstances only in which valvular murmurs were heard. "The
bellows murmur," says he, "attends the contraction of the left auri-
cle (by which must now be understood the ventricular diastole or
second sound) when the mitral valve is affected, and that of the
ventricle when the induration affects the sigmoid valves of the
aorta." He does not expressly say whether he intends these signs
to apply equally to the valves of the right side, but the following
general statement will perhaps admit of that construction : — " Bel-
lows murmur exists almost constantly in the orifices of the heart in
individuals affected with contraction of the orifices of that organ."
(ii. 441.)
M. M. Bertin and Bouillaud, in 1824, adopted, without extend-
ing, the valvular murmurs of Laennec, but they distinctly apply
them to the right, as well as to the left side. (Traite, p. 225.)
Neither these authors, nor Laennec, nor any French writer was
acquainted with murmurs from regurgitation through the several
valves; and as they necessarily confounded these with the other
murmurs, I have not the slightest doubt that it was this circum-
stance, as well as Laennec's erroneous idea that murmurs might
result from mere spasmodic contraction of the heart and arteries.
96 HOPE ON DISEASES OF THE HEART.
(Traite II. 440,) which caused this acute observer to contradict
himself in his second edition by saying " bellows-murmur does
not suppose any organic lesion in the heart and arteries." (Traite
II. 443.)
To the murmurs of Laennec, I added, in the first edition of this
work in December 1831, the murmurs from regurgitation, thus
assigning to each valve a double murmur — one, from the blood
flowing in the natural direction; the other, from its flowing retro-
grade when the valve was permanently patescent.1 I at the same
time controverted the murmur from spasm of Laennec,2 and showed
by the experiments and arguments offered under the subjoined
head of murmurs of the heart and arteries independent of organic
disease, that the murmurs did not depend on spasm, but on other
very appreciable causes; and that they were easily distinguishable
from the murmurs of valvular disease. Eight years of additional
experience have confirmed me in the general accuracy of the views
which I then took ; but a fuller and more precise knowledge of all
the circumstances now enables me to correct a few minor errors,
and to make such additions as will, I hope, render the diagnosis of
valvular disease not only the most certain connected with the
whole subject, but so simple and easy as to be readily attainable by
the meanest capacities.
The circumstances under which I have found murmurs pro-
duced in the several valves respectively, are as follows.
Aortic Valves. 1. Systolic murmur. I have found a murmur
attend the ventricular systole in every degree of fibrous, fibro-car-
tilaginous, steatomatous and osseous disease of the aortic valves
sufficient to contract the aperture. The same remark applies to
vegetation on the valves or in the orifice. I have even found con-
siderable murmur produced by mere osseous or even steatomatous
1 Dr. Elliotson, I find, published before myself the fact that permanent
patency of a cardiac opening was a source of bellows sound. He candidly
adds, "I heard it first from Dr. James Johnson. Who originally suspected
it, 1 cannot say. Dr. Johnson imagined he had learned it from Laennec
and other writers upon auscultation ; but I have found no other notice of it
than the erroneous view of Bertin." (Lumleyan Lees. p. 20, 1830.) I be-
lieve I can explain this. Dr. Johnson probably learned it from his son, to
whom I had communicated it; for in 1829 and 1830, he and I studied aus-
cultation together in St. George's Hospital, and I was in the habit of point-
ing out the regurgitations as a discovery of my own, made in June 1825, in
the remarkable case of Christian Anderson, for which, see Index to the
cases. I also taught the regurgitations at St. Bartholomew's Hospital in
1S26, and at La Charite, Paris, fn 1827.
Dr. Corrigan, not aware of Dr. Elliotson's publication or my own, sub-
sequently published a paper in the Edin. Med. and Surg. Journ. No. III. for
1832, " On a new disease of the heart : viz. permanent patency of the mouth
of the aorta."
2 Dr. Corrigan, I find, had previously donethe same in the Lancet of 1829,
of which I was not aware. More recently, in 1835, M. Bouillaud has fol-
lowed in the same track. This doctrine, in short, is now universally ex-
ploded.
PATHOLOGICAL PHENOMENA. 97
asperity of the valves, without contraction — at least, such as could
be appreciated : a fact which is easily explained, since it is known
that mere roughness, by increasing friction, will produce sound. I
have also found murmur created when, without contraction or
roughness of the valve or orifice, the aorta immediately above the
valves was dilated either in its whole circumference, or partially so
as to form a pouch. Here the stream is broken by the divergence
of the blood, just in the same way as when it passes from a con-
tracted orifice into a natural sized aorta. I have found a very loud
bellows-murmur produced by an opening, admitting the index
finger, from the right ventricle into the mouth of the left ventricle
and the aorta (case of Collins); and I have noticed the same mur-
mur in four other cases of malformation with Cyanosis, in which I
had not the opportunity of post mortem inspection.
[A very rough bellows-murmur, a whizzing, or rasping sound is heard
over and above the aortic orifice, when a ridge of cartilaginous or ossific de-
posit is formed around the internal circumference of the ascending aorta
near its valves, although these valves may be in a normal condition. If the
lesion be near the cardiac origin of the artery, the second sound is frequently
obliterated. In a case of dissecting aneurism, where a laceration of the in-
ternal coat and a partial rupture of the middle coat had taken place half an
inch above the valves, thus permitting a portion of the arterial blood to pass
from the artery into the factitious channel, an extremely rough whizzing
sound, similar to the puff of steam from a boiler, replaced the first sound,
and the second was absent. These changes of structure prevent the forma-
tion of the second sound by interfering with the reflux of the arterial column
upon the aortic valves, by which these valves are closed, and the second
cardiac sound is formed. — P.]
The murmur discovered by Dr. Latham as attending pericarditis,
and which he communicated to me in 1826, I soon ascertained to
proceed in many cases from the interior of the heart; as I found it
continue after the pericarditis had ceased, or the pericardium become
adherent. I therefore expressed my belief, in the first edition of
this work, that the systolic murmur "might, in some instances,
originate partly on constriction of the arterial orifices consequent on
inflammation of the lining membrane. For as this membrane is
more liable to inflammation where it constitutes the valves, than
elsewhere, it is consistent with analogy to suppose that, by its in-
tumescence and loss of elasticity, the orifices will undergo the con-
striction alluded to. The murmur accompanying the second sound,
I am inclined to attribute perhaps entirely to the same constriction,
affecting the auriculo-ventricular orifices" or (I should have added)
occasioning patency of the sigmoid valves. The accuracy of this
opinion has been fully substantiated by my subsequent experience
in a great number of cases, and by the researches of Dr. Elliotson,
Dr. Watson, Dr. Stokes, and M. Bouillaud.1
1 When I published the above passage in the first edition, I was under the
impression that the fact was new. I find, however, that Dr. Elliotson had
preceded me in its publication, in his Lumleyan Lectures, which I had not
had the good fortune to see. M. Bouillaud in 1835 has mis-stated my opi-
9— b 7 hope
98 HOPE ON DISEASES OF THE HEART.
Concretions of blood in the heart, if formed before death (of
which adhesion and organisation are the best anatomical criteria),
may-occasion murmurs, either by obstructing an orifice or pre-
venting a valve from closing. They occur principally in acute
endo-carditis. I state the fact mainly on the authority of M. Bouil-
laud, as I do not happen to have lost a patient with acute inflam-
mation of the heart during the last eight years, nor have I noticed
the murmur in ordinary cases of polypus before death. Others,
however, have. Dr. Elliotson describes a case in his Lumleyan
Lectures, p. 18. On the whole, I should think murmur from this
cause very rare : and I should imagine that a polypus would be
more apt to entangle, and create a murmur in the auricular valves,
than in the semilunar.
[The stale of the circulation has an important influence upon the produc-
tion and modification of abnormal systolic murmurs. Very frequently, dur-
ing a state of entire tranquility with a slow and equable pulse, a lesion of
the aortic orifice may not be detected, but, should the force of the heart's
action be increased, either by exercise, disease, or mental emotion, the ab-
normal sound is instantly developed. In fact all the abnormal first sounds
of the aorta are increased by the augmented force of the heart's action : thus,
the blowing sound may become whizzing, or rasping, and the musical mur-
mur be raised in pitch, and the like.— P.]
2. Diastolic murmur of the aortic valves or from regurgitation.
I have known this to be occasioned by all the varieties of fibrous,
fibro-cartilaginous, steatomatous and osseous disease, and also by
inflammatory tumefaction in acute and chronic endo-carditis — one
of the most frequent causes of regurgitation. In fact, if any of
these diseases contract, or otherwise deform, one or more of the
valves, so as to prevent complete occlusion of the orifice, the mur-
mur is produced. I have seen it result from the angles of the
valves being detached from their insertions by steatomatous disease
(case of Copas) ; also from a tear of a valve near its angle. (Mil-
ton and Figs. 10 and 11.) I have no doubt that it may also occur
from atrophy of the valves producing perforations, though I do not
happen to possesss an unequivocal case. I have once seen a canal
from steatomatous disease, admitting the little finger, and half an
inch long, pass under the base of an aortic valve and the lining
membrane of the heart into the left ventricle; and, though I did
not see the patient before death, I have no doubt, from the jerking
pulse, that there was regurgitation and therefore a diastolic mur-
mur. (Case of Brown.) I have once seen regurgitation and murmur
from an aneurism of the aorta immediately above the valves, open-
ing into the right ventricle immediately below its valves. Mitchell,
Fig. 21.) Though this does not strictly come under the head of
disease of the valves, yet it is convenient to notice it here as a pos-
nion, though so distinctly expressed in the above quotation. He says " M.
Hope has, at least, had a glimpse (a entrevu) of the influence of endo-car-
ditis in producing bellows-murmur," and adds that I restrict it to the dias-
tole !
PATHOLOGICAL PHENOMENA. 99
sible source of fallacy. On the same principle I may add that, in
the case of Evans, regurgitation with murmur resulted from two
perforations out of the ascending aorta into the pulmonary artery.
Finally, I have seen regurgitation with murmur from mere en-
largement of the aortic orifice, whence the valves, otherwise sound,
were incapable of closing it. (Case of R. S., Esq.) Figs. 6, 13, 14,
15, 16, 17, 18 and 20, are of the aortic valves.
[The thickening of the aortic valves from cartilaginous deposit, etc. ren-
ders them less elastic, contracted, so that a permanent opening near their
free edges in that lesion is frequent. This state of the valves modifies the
second sound, producing when the heart is perfectly tranquil, a blowing
muimur. When the patient is agitated, this sound may not be observed,
owing to the loud first sound, caused by the rapid passage of the blood
through the aortic orifice, masking the second. Permanent patency from
the thickening of the semi-lunar valves is most frequently met with, when
the alteration of the valvular structure occurs near their bases, where they
originate from the parietes of the aorta. — P.]
I have noticed three circumstances characteristic of aortic regur-
gitation, to which, after examining a great number of cases, I have
not yet met with an exception. 1. The murmur is soft, like bel-
lows-murmur, or still more like gently sucking in air through the
lips only moderately closed, as in pronouncing the word awe: and
it is weak, as compared with the much greater intensity which sys-
tolic murmurs may attain in the same situation, In the first edition,
I explained this weakness as follows — "I have never found it
(the diastolic murmur) strong, and I doubt whether it can be so, as
the instantaneous manner in which the ventricle is refilled by its
diastole, must prevent the regurgitation from being considerable."
Another conspiring cause, however, may be added ; namely, that
the aortic retrograde pressure is inferior to that of the left ventricle,
and therefore it could not retropel the blood with equal force and
velocity. 2. The murmur is generally very prolonged — a long
sigh, tailing, as it were, the second sound and often extending com-
pletely to the next ventricular systolic sound: in one case (W ....
Esq.) I even found it prolonged completely through intermissions
of the heart's beats. This prolongation I ascribe to the pressure in
the aorta being continuous or incessant, and to there being nothing
to interrupt it but the next ventricular contraction. 3. The mur-
mur is more audible than a systolic murmur is below the sigmoid
valves and down the ventricle, though, notwithstanding, it decreases
as it descends. This obviously proceeds from the current setting
into, and exciting sonorous vibrations within, the cavity of the
ventricle. The circumstance is of importance in a diagnostic
point of view ; for it might create the erroneous belief that the mur-
mur was seated in the mitral, instead of the aortic valves (as both
occur during the diastole), unless the auscultator were careful to
ascertain that it was loudest at, or above the aortic valves, where
a mitral diastolic murmur, always feeble, would be wholly inau-
dible.
V
100 HOPE ON DISEASES OF THE HEART.
[The mitral murmur is strongest near the apex of the heart.
In my clinical researches on the heart, for more than two years past, I
have constantly directed my attention to the region near the apex of the
heart, as the situation where the abnormal sounds of the mitral valve are
most perceptible. This view was stated at a meeting of the Pathological
Society of Philadelphia, held on the 6th of January 1840 : at that time I
was not aware of similar views being entertained by European pathologists,
and it was not until the republication of Tweedie's Library last year, that I
was made aware of the fact.
It is very gratifying to me that Dr. Hope, in his extensive observation,
has located the seat of the abnormal cardiac murmurs, where I had been ac-
customed to look for them previous to the publication of his work. — P.]
The murmur of aortic regurgitation is of very frequent occur-
rence, though it is commonly supposed to be rare : the reason of
which is, that, before the discovery of the regurgitations (with
which many are still but little acquainted), it was necessarily and
invariably mistaken for a murmur with the second sound from con-
traction of the mitral valve. I habitually made this mistake myself
before 1825, when I first noticed the regurgitations, and I distinctly
see the same mistake in two or three of Dr. Elliotson's cases pub-
lished in his Lumleyan Lectures in 1830— cases probably taken
before he had heard of the regurgitations in the manner above
described. He says, for instance, that the murmur was of a " suck-
ing or aspiring" character, that it was "slower," and that it was
loudest at the upper part of the heart. In conclusion, I have traced
aortic regurgitation and murmur to acute rheumatic endo-carditis
far more frequently than to any other cause.
Pulmonic Valves. 1. Systolic murmur. I have never once
met with, and ascertained after death, such disease of the pulmo-
nic valves themselves as created a murmur during life. Others,
however, have, though very rarely ; for, according to Dr. Clen-
dinning's observations on one hundred cases, with which my own
very nearly coincide, the total proportion of valvular disease on the
right side of the heart is only about one in sixteen. 1 have
seen two or three cases, without autopsies, in which I believed
the valves to be diseased; but they were principally cases of
cyanosis, in which the valvular disease is usually congenital. I
have also once seen the orifice of the right ventricle contracted to
the size of a quill an inch below the valves, in a case of cyanosis
with an opening out of the right into the left ventricle. (Collins.)
Here, the systolic murmur proceeded from both of the morbid aper-
tures. I have once seen an aneurism of the origin of the aorta
bulge into the mouth of the right ventricle and contribute to a sys-
tolic murmur and thrill over the part. (Case of Mitchell and Fig.
21.)
Dr. Elliotson describes two cases in which lumps of cartilage in
the pericardium pressed upon, and contracted the pulmonary artery,
so as to create a murmur. I have once met with a case, probably
unique, of extensive ossification of the trunks of the pulmonary
artery within the lungs, which produced a systolic murmur. (Lady
PATHOLOGICAL PHENOMENA. 101
R.) I mention this as a source of fallacy, though it does not pro-
perly come under the head of valvular disease. Dilatation of the
pulmonary artery is another source of fallacy, which will be noticed
under its proper head. (See Dil. of Pulm. Artery, and cases of
Weatherly and L. P.)
Thus it would appear that the majority of cases of systolic mur-
mur in the pulmonic orifice, are connected with lesions, not of the
valves themselves, but of contiguous parts.
2. Diastolic murmur of the pulmonic valves. I believe this to
be exceedingly rare from disease of the valves themselves, as I have
never met with a case, or been able to find one recorded. In
Mitchell, the origins of the valves were stretched and separated by
the aortic aneurism, so as probably to admit of regurgitation and
murmur. (See Fig. 21.) In Weatherly, the pulmonic orifice was
greatly dilated, yet the valves must have closed it, as there was no
diastolic murmur. I created this murmur artificially in an ass
poisoned with woorara, by making a perforation through one valve.
We found the murmur soft, prolonged, and audible down the
ventricle, exactly as in aortic regurgitation. In the human sub-
ject the pulmonic would probably be louder than the aortic dias-
tolic murmur, because its seat is nearer the surface.1
From a rude numerical calculation deduced from the cases that
I have seen, I should think that there would be at least thirty
chances to one against a murmur connected with the semilunar
valves, being seated in the pulmonic set.
Mitral Valve. 1. Systolic murmur, that is, from regurgitation.
It was the existence of this murmur in Christian Anderson, who
had no disease of the semilunar valves, that led me to the detection
of regurgitations in general in June 1825. Since then, I have met
with the murmur from every variety and degree of fibrous, fibro-
cartilaginous, and osseous disease of the mitral valve and chordae
tendineaa capable of holding the valve permanently open : also,
from vegetations. Dr. Elliotson met with it from an organised
polypus. It cannot be too strongly inculcated that a slight pa-
tency of the valve admitting of regurgitation, may result from a
structural lesion not sufficient to present an obstacle to the blood
flowing in its natural direction from the auricle into the ventricle.
Thus, I feel certain that there is no one lesion which more fre-
quently produces regurgitation than shortening, usually with thick-
ening, of the chordas tendineae (e. g. case of Dennis); yet how
constantly do we see this lesion completely overlooked, and the
valve pronounced capable of discharging its function, because it
will allow two or three fingers to pass through it ! Another,
[» This is doubtful, inasmuch as the second sound over the pulmonary ar-
tery and valves of the exposed heart of the living animal, has a less degree
of loudness than the same sound over the aortic valves. This probably
arises from the fact of the risrht ventricle contracting with less force than
the left.— P.]
102 HOPE ON DISEASES OF THE HEART.
though less common lesion, apt to be overlooked, is, adhesion of
one or both divisions of the valve, especially the posterior, to the
walls of the ventricle, — a result of inflammation. Dr. Elliotson
gives cases of this in his Lumleyan Lectures in 1830. M. Bouil-
laud, in 1835, treats of it more fully as a previously unknown
lesion. (Traite, II. 183.) A sUtt more rare source of regurgitation,
is, atrophy of the valves rendering them morbidly thin and small,
and sometimes attended with cribriform perforation of the mem-
branes. Attention has been drawn to this by Dr. Kingston, in the
Medico-Chirurg. Trans. See Figs. 5, 7, 12 and 15.
I have also met with regurgitation and murmur from another
circumstance apt to be overlooked ; namely, dilatation of the orifice
consequent on dilatation of the ventricle, rendering the valve, other-
wise healthy, incapable of closing it. I witnessed a sti iking instance
of this in a valuable horse which Mr. Field requested me to see.
I found the murmur of mitral regurgitation, and, from the weak-
ness and irregularity of the pulse, judged the reflux to be extreme.
The animal died on the following day, and Mr. Field pronounced
the mitral orifice to be double its natural size and the valve totally
incapable of closing it. The same conditions appear to have ex-
isted in the case of H . . . y, Esq., as the murmur ceased when he
recovered from the dilatation of the heart.
The murmur of mitral regurgitation is loud, considering the
depth of its seat, because it is occasioned by the great force of the
ventricular contraction. When, however, that force is much
diminished by Softening or by Dilatation with Attenuation, the
murmur may be much more feeble — nay, sometimes even extinct.
I have for instance, met with several cases, in which a murmur
attended every strong contraction of the ventricle, while the two
or three following contractions, so feeble as barely to occasion a
pulse, were productive of a valvular click only, without murmur.
In another case (Mrs. 1 -n) in which the left ventricle was
dilated, attenuated to one third of an inch, and greatly softened,
and the mitral valve contracted into a slit which only admitted a
writing quill, no mitral murmur attended either the systole or dias-
tole.
Of all murmurs, that from mitral regurgitation is, according to
my observation, the most frequent. Dr. Elliotson, in 1830, said it
was rare, and that aortic systolic murmurs exceeded all others in
frequency (Lumleyan Lectures, p. 22): but at the period \o which
his remarks refer, he appears to have been practically unacquainted
with the regurgitations, and therefore included mitral regurgita-
tions under the head of aortic murmurs. M. Bouillaud, in his work
in 1835, seems equally disposed to give the numerical predominance
to aortic systolic murmurs, and apparently for the same reason ;
for, from his avowed inability to distinguish the particular seat of
valvular disease, and from his remark that he believed M. Filhos
had attached too much importance to regurgitations, it is. evident
PATHOLOGICAL PHENOMENA. 103
that he could not have had much practical knowledge of them at
that period.
[Regurgitation through the mitral valve during the systole of the heart,
often takes place without any striking organic lesion in persons of irritable
temperament, upon the occurrence of any mental agitation or upon any sud-
den exertion. Under such circumstances, the systole of the heart is accom-
panied by a slight blowing sound, heard near the apex, not perceptible over
the aorta, and ceasing when the disturbing cause has passed by. It is pro-
bably produced by a slight irregularity in the contractile power of the
columnar carneae, in consequence of which, all parts of the mitral valve are
not simultaneously rendered tense. — P.]
2. Diastolic murmur of the mitral valve. Any lesion of the
valve capable of sufficiently contracting its aperture may, under
the limitations presently to be described, give rise to this murmur.
It was one of the only two murmurs discovered by Laennec, and
was long supposed to be of frequent occurrence. But I believe that
this opinion is incorrect, and that it has resulted from the murmur
having been confounded with that from aortic regurgitation: for,
since I have been able to detect the latter with certainty, I have
found the mitral diastolic murmur to be exceedingly rare. It was
stated in the first edition of this work that "a slight contraction,
such as, for example, to diminish the circumference by a quarter,
or from that to half au inch, does not occasion any appreciable mur-
mur with the second sound ; for the blood has still sufficient space
to pass with tranquillity." It was likewise stated that "a contrac-
tion of the mitral or tricuspid valve to the size of only two, three,
or four lines in diameter, I have frequently known to occasion little
or no murmur" with the second sound. Much subsequent inves-
tigation (in the course o( which I have met with very few cases of
this murmur) has led me to ascribe its feebleness when it does
exist, and its absence in circumstances under which it might have
been expected, to the weakness of the current of blood flowing
during the diastole from the auricle into the ventricle. This weak-
ness allows the blood to pass in silence through the aperture when
only slightly contracted ; and when the weakness is prelernaturally
augmented by debility of the heart, even a high degree of contrac-
tion is unproductive of sound. Thus, in Christian Anderson, the
tricuspid valve was a thick cartilaginous ring, admitting the middle
finger; and the mitral valve, a similar ring, admitting the little
finger; yet, as the action of the heart was exceedingly feeble, the
pulse and impulse being imperceptible, these lesions were unat-
tended with diastolic murmur, though productive of a loud systolic
one from regurgitation. Similar remarks apply to the cases of
Sharpe and of Mrs. 1 n. One of the best marked cases of
the murmur in question which has occurred to me for some years,
1 examined a few days ago. In N . . ., Esq. there was a loud sys-
tolic murmur from regurgitation through the mitral valve, followed
by a soft, subdued diastolic murmur, louder an inch above the apex
than elsewhere, and gradually decreasing on ascending to the sig-
104 HOPE ON DISEASES OF THE HEART.
moid valves, which did not present any murmur from regurgitation
for which the other could be mistaken.
Will it be said that the auricular contraction, previous to the
ventricular, should create a murmur ? I have looked for it care-
fully, and have only once been able to suspect it, without being
able to assure myself of its existence. Theoretical reasoning seems
to countenance this result of observation ; for, as the auricular sys-
tole is slight, (See Exp. p. 42,) the quantity of blood injected by it
is not considerable; and as the ventricle is already full, it cannot
admit that extra quantity necessary to bring it to the state of dis-
tention, without offering a resistance to its ingress which must
greatly retard the force and velocity of the current : —a force, indeed,
which can never be great, because the auricles are not only weak
muscles, but are unsupported by valves behind.
Tricuspid Valve. 1. Systolic murmur, or from regurgitation.
I have seen this occasioned by cartilaginous contraction of the
valve to the size of the middle finger. (Anderson.) Dr. Elliotson
mentions two or three cases of adhesion of the valve to the ventri-
cular walls, permitting regurgitation. I have several times seen
the same in the dissecting room. Dilatation of the ventricle, by
enlarging the orifice, may create patency of the valves. Systolic
murmur of this valve is rare, 1. Because valvular disease does not
occur oftener than about once on the right side of the heart for six-
teen times on the left ; 2. Because, when it does occur, it is almost
always much less in degree and usually not sufficient to disable the
valves.
The murmur may be loud, because it is occasioned by the con-
siderable power of the right ventricular systole, and because, being
nearer the surface, it is more audible than a mitral murmur of
equal intensity.1
2. Diastolic murmur of the tricuspid valve. This is so rare
that (abstracting pulmonic and aortic regurgitant murmurs, with
which it is apt to be confounded) I am not satisfied that I have
ever met with an instance of it. In Anderson it did not exist,
though the aperture was a ring admitting the middle finger. The
reason assigned for the rarity of diastolic murmurs in the con-
tracted mitral valve, namely, the feebleness of the current of blood,
applies equally to the tricuspid.
[The tricuspid valve has been regarded by many physiologists as a valve
of safety, admitting of regurgitation of blood backward through the auriculo-
ventricular orifice, whenever there is a tendency to a surcharge of that fluid
in the right ventricle. This view is extremely plausible, and as the regur-
gitation occurs in this case as a conservative principle, we should anticipate
that no murmurs similar to those observed from regurgitation through the
mitral valve would be presented whilst the tricuspid valve retained its normal
[' This murmur should be sought for over the right ventricle near the
junction of the cartilage of the fifth rib with the left side of the sternum;
because, at this point the columnae of the tricuspid valves are inserted into
the walls of the right ventricle and into the septum. — P.]
PATHOLOGICAL PHENOMENA. 105
structure. I do not recall an instance where a murmur from regurgitation has
been reported where the valve presented its normal structure, whilst these
sounds have often been observed when the valve was thickened, or offered
some adventitious obstacle to the course of the blood. — P.]
Such are the circumstances under which I have noticed valvular
murmurs. We now proceed to consider —
The Mechanism and Varieties of Valvular Murmurs.
Valvular murmurs are occasioned by collision of the particles
of the blood against each other, and against the containing solids,
when this fluid is, by any cause, thrown into preternatural com-
motion during its passage through the orifice of a cavity. This
commotion produces sonorous vibrations in both the fluids and the
solids.1 To offer an experimental exemplification of this — a simi-
lar murmur is produced when water is transmitted with sufficient
velocity through a tube, in any part of which there exists an inter-
nal prominence or contraction of its calibre. The same occurs
when the leather pipe of a fire engine is slightly compressed with a
finger ; or when similar compression is exercised with the stetho-
1 M. Bouillaud expresses the same idea in the following terms: "The
element to which we ought, rationally and experimentally, to refer the bel-
lows-murmur that accompanies contraction of an orifice from induration of
the valves, is, an increase of friction during the passage of the blood through
the orifices or cavities of the heart." (Traite I. 182.) Dr. Corrigan is mis-
taken in thinking that all explanations of bruit de soufflet have been imper-
fect because they did not embrace the two following " conditions, which (in
his opinion) constitute the mechanism of bruit de soufflet: 1st. A current
like motion of the blood (instead of its natural equable movement), tending
to produce corresponding vibrations in the sides of the cavities or arteries
through which it is moving." Now, what is a current like motion but an-
other name for the "preternatural commotion." the "increase of friction"
above expressed ? Dr. Corrigan proceeds "2dly, A diminished tension of
the parietes of the arteries or cavities themselves, in consequence of which,
these parietes are easily thrown into vibrations by the irregular currents of
the contained fluid." (Dublin Med. Jour. x. 180.) Now, this condition is
incorrect. For it has been proved by Mr. Wheatstone that the vibration of
solids is not indispensable to the production of murmurs, since he has pro-
duced them in the most rigid cast iron tubes by the vibration of liquids alone.
Nor has Dr. Corrigan been fortunate in the selection of the following in-
stance as the strongest foundation for his argument: "In narrowing of the
auriculo-ventricular opening of the heart," says he, "the two conditions
necessary to generate the sound are in high perfection; and hence, of all the
lesions with which bruit de soufflet is connected, it is in this that the sound is
most constant." (Ibid. p. 183.) I have shown above that this is a reproduction
of the old fashioned error of Laennec, resulting from aortic regurgitant mur-
mur being mistaken for direct mitral; and that the latter is, of all murmurs,
one of the least frequent and constant. So great a mistake is more surpris-
ing in Dr. Corrigan, since he has written on aortic regurgitation as a sup-
posed new disease.
The fact, then, respecting murmurs briefly is, that they may be produced
by the vibrations either of the liquid alone, or of the liquid and solids con-
jointly ; and the latter is without doubt the more frequent case in the heart
and arteries, because these solids are elastic. Hence it is, that vibratory
tiemour is in many instances perceptible to the touch.
106 HOPE ON DISEASES OF THE HEART.
scope on a superficial artery of primary or secondary magnitude,
as the subclavian below the clavicle, the carotid, the femoral, &c;
or when the denuded aorta or pulmonary artery is compressed, as
in the ass poisoned with woorara. (Exp. p. 55, Obs. 14.)'
[" At the moment when the blood is expelled from the ventricle, if, instead
of a smooth, equally tense channel, it meets with a rigid constriction or an
abrupt orifice, its passage through it will be attended with a whizzing or
blowing noise which may be heard in the region of the heart. Or, to take a
simple case; if you apply the stethoscope in the course of an artery far from
the heart, you will hear nothing as long as the current of blood flows
smoothly and unmodified through it; but if by pressure you diminish the
calibre of the tube at any point, you then complete the elements of sound;
you give resistance to the moving blood, and at each pulse you hear a blow-
ing or whizzing sound, which will vary in tone and loudness according to
the force of the current and the degree of resistance which it meets with.
This is purely a physical phenomenon; you may produce it in any tube
through which a current of water runs. Thus, if you take an Indian-rubber
tube, and adapt it to a reservoir of water, so that the water shall flow freely
through the tube, you may, by pressure on the tube, produce murmurs, vary-
ing according to the force of the current and the resistance which the pres-
sure opposes to it. They are sometimes like blowing; sometimes, like
rasping or sawing a piece of wood; and now and then they may be heard
in quite a musical tone, which implies that the vibrations are then regular
and sustained. The blowing and musical murmurs are generally caused by
greater regularity but less force of current than that which produces the
sawing or whizzing sound." — Lectures of C. J. B. Williams. — P.]
Murmurs present several varieties, which Laennec has designated
by the epithets bellows-murmur, sawing or filing, rasping, a con-
tinuous murmur like that in a large sea-shell, and a whistling or
viusical murmur. By bellows-murmur, he meant a smooth, soft
tone, like that of blowing with hand-bellows. By sawing, filing,
and rasping, he meant to indicate merely successive degrees of
roughness (Traite, ii. 423), without including, as is too commonly
imagined, the pitch or key of the note. M. Bouillaud does not
seem clearly to have understood this distinction : at least, he has
not clearly marked it. (Traite, torn. i. 167 and 187.) Thus, he
says that whispering the letter s, is an exact imitation of the saw-
ing murmur; but that a similar whisper of the letter r, is thicker
(plus gr as) than the sawing sound. Here, he evidently considers
the key, and not the roughness, to be the characteristic of the saw-
1 It is remarkable that, though Laennec adopted the view that bruit de
soufflet of the heart and arteries was referable to "a sort of spasm or ten-
sion," the true view did not escape him; for he mentions as the other alter-
native which he rejected, that the murmur "owed its origin to a particular
state of the blood, or to the manner in which this liquid was moved." (Traite,
ii. 429.) Dr. C. J. B. Williams is therefore mistaken in supposing himself
to have been the author of the conjecture that bruit de soufflet was referable
to " the motion of liquids in, or against solids of a particular form. (On the
Pathol, and Diag. of Diseases of the Chest, p. 193, 1835.) He is also mis-
taken in supposing that I adopted this view; for, as explained in a note at
p. 58 of this work in 1831, my own opinions were in print before I had seen
the above words in his Rational Expos, p. 50.
PATHOLOGICAL PHENOMENA. 107
ing sound. A slight degree of roughness, Laennec designated by-
comparing it to the distant filing or sawing of wood ; and a high
degree, by comparing it to the rasping of wood.
Laennec imagined that the rougher murmurs of filing, sawing,
and rasping denoted ossification f and that the softer or bellows-
murmur was connected with obstructions presenting a smooth sur-
face as the fibrous and cartilaginous — a view which MM. Bertin
and Bouillaud adopted, and which M. Bouillaud does not wholly
discard in his later work. (Traite, i. 187.) I feel confident, how-
ever, from the examination of a great number of cases, that the view
is not so correct as to admit of being adopted as a general rule. It is
true that rough, denuded, salient ossifications will occasion a rasp-
ing murmur, because they effectually break the current of the blood ;
but I have repeatedly known less prominent ossifications, especially
when still covered by the lining membrane of the heart, occasion
merely a soft bellows-murmur. On the other hand, in innumera-
ble cases, I have found sawing, filing, and even rasping murmurs
produced by merely fibrous or fibro-cartilaginous disease, which,
in many cases, I ascertained by dissection, but, in others, merely
inferred from the youth of the patient or the recent date of the dis-
ease. Dr. Elliotson imagines that degree of contraction is the sole
essential to roughness. (Lum. Lee. p. 15.) That a considerable
degree of contraction is an important essential, I do not doubt; but
that the roughness is always in the direct ratio of the degree of
contraction, is a proposition from which lam bound to dissent ; for
I have habitually found the highest possible degrees of contraction
attended with soft bellows-murmur. For instance, mitral regurgi-
tations, often occurring through a chink so small as not to impair
the strength of the pulse, frequently yield a perfectly soft, though
possibly a loud bellows-murmur, for softness and loudness are by
no means incompatible circumstances.
Hence I conclude that the roughness of murmurs is neither con-
nected with any particular anatomical element of the valvular lesion,
nor directly proportionate to the degree of contraction ; but that it
depends upon such an accidental configuration of the contracted
orifice as is best calculated to break the stream of the blood, and
throw it and the contiguous solids into large vibrations — a configu-
ration with which I have generally found a considerable though not
necessarily a high degree of contraction to coincide. ■ Considerable
1 How much the discharge of fluids is connected with the configuration of
the apertures, is illustrated by the experiments of Venturi. He found that
any vessel or reservoir discharged less through a simple, circular hole in its
base — viz. only 62 quarts in 100 seconds, than through one to which was
affixed a short tube, of the same diameter as the hole, and twice the length
of its diameter, from which the discharge was 82 quarts. He found, again,
that, if the tube was pushed up some distance into the vessel, the flow of
water was diminished, even to less than issued from the simple aperture,
namely, to less than 62 quarts.
Sir Isaac Newton had previously ascertained, that fluid, tending from all
parts of a reservoir to one common centre or orifice in the bottom, proceeded
108 HOPE ON DISEASES OF THE HEART.
strength of the current, however, is a further essential to roughness;
as is shown by the facts that no roughness attends the murmurs
from sigmoid regurgitation or influx from the auricles into the ven-
tricles, and that rasping murmurs may often be made temporarily
soft by bleeding, digitalis, &c.
To sum up, then, the presumptions afforded by a rough or rasp-
ing murmur would be 1, that the cause is organic, for inorganic
murmurs, as will hereafter be shown, are never rough ; 2. that the
contraction of the orifice is not inconsiderable; 3, that if the mur-
mur occur after the age of 60, the disease is probably osseous.
The continuous murmur. Laennec says, " In very rare cases,
the bellows-murmur changes, in the carotids especially, and even
in the heart, into a continuous murmur analogous to that of the sea,
or to that which we hear on placing near the ear a large univalve
sea-shell. (Traite, ii. p. 422.) I shall hereafter prove that Laen-
nec and his follower Bouillaud have been mistaken in referring con-
tinuous murmurs to the arteries, their real seat being [generally] in
the veins, where, so far from being rare, they are very common.
Laennec does not allude to the circumstances under which continu-
ous murmur occurs in the heart, nor have they, to my knowledge,
been explained by other authors: I shall therefore offer the results
of my own observation. I have twice heard continuous murmur
in the heart, in a very marked degree. In one case (Jones), it de-
pended on the moderate quantity of fluid churned, as it were, in the
pericardium rough with lymph. In the other case (Mitchell), it
was occasioned by regurgitation out of an aortic aneurism into the
right ventricle. In both, though continuous, it was augmented in
intensity during the ventricular systole and diastole ; and in both it
was attended with a great degree of purring tremour.
I have two or three times met with continuous murmurs, aug-
mented synchronously with the pulse, along the tract of the pul-
monary artery, apparently in connection with dilatation of the
vessel (case of Miss L. P.); but I suspect that while the augmenta-
tions were seated in the artery, the continuous portion of the mur-
mur resided in the vena innominata, compressed or displaced by the
in curves. It occurred to Venturi that, such being the natural form in which
water tends to discharge itself, a pipe of that form would favour the dis-
charge : and, accordingly, he found this to be the case, the amount being 98
quarts. Conceiving, further, that the curve in which water naturally tends
to an orifice, was, from the inertia of water, continued beyond the point of
discharge, he made the pipe trumpet-mouthed beyond its narrowest point, in
the same curve as before it; and from this he obtained the maximum dis-
charge.
These differences in the quantity of discharge from orifices of the same
area, depend on the degree in which the currents cross each other at the
orifice, and thus constitute a greater or less obstruction to the direct passage
of the whole body of fluid. It is obvious that the deg'ree of obstruction will
be greater in proportion as the currents cross at greater angles, and that it
will be still further increased by any counter currents oreddies opposing the
converging currents. It will be easy for the reader to see the application of
these experiments to the various valvular contractions.
PATHOLOGICAL PHENOMENA. 109
dilatation. This subject will be explained under nervous murmurs.
See especially the case of James.
The bellows, sawing, rasping, and continuous murmurs in the
heart are louder, caeteris paribus, in proportion as the stream of
blood through the contracted orifice is stronger. This, which is
obvious on theoretical grounds, I have found amply confirmed by
observation. Thus, murmurs are increased by accelerating the
heart's action, and diminished by calming it, especially if the pulse
be much lowered by digitalis. Again, I have collected six or seven
cases of valvular disease, in which there was one strong contrac-
tion of the ventricles producing a pulse, followed by two or three
feeble contractions attended with a barely perceptible pulse. ' The
strong contractions occasioned a murmur; the weak, none. Again,
the currents by regurgitation through the sigmoid valves, and those
flowing out of the auricles into the ventricles through the con-
tracted auricular valves, are more feeble than the currents setting
in the opposite directions, that is, out of the ventricles ; and the
corresponding murmurs I have invariably found to be weaker.
The strength of the current, however, is not the only circumstance
which occasions loudness of murmurs ; for such a configuration of
the stricture as most breaks the stream, produces not only a rougher
murmur, as already shown, but one of greater intensity. Accord-
ingly, we find rough murmurs, caeteris paribus, louder than others,
with the exception of musical tones, these being, from their acute
nature, more calculated for transmission to a distance.
The pitch or key of the bellows, filing, sawing and rasping mur-
murs (as distinguished from their roughness) depends mainly on
the depth or distance from the surface at which murmurs are gene-
rated, the pitch being higher in proportion as they are nearer, and
vice versa; but it is also slightly elevated by a stronger current
and depressed by a weaker. A very narrow aperture raises the
key, provided the current be strong. These circumstances were
pointed out by Laennec or the other French writers ; whence has
resulted the prevailing confusion respecting the meaning of the
above epithets, filing, sawing, &c. After much attention devoted
to this point, I think that the following characters will be found at
once tolerably accurate and easy of comprehension.
Murmurs seated in the pulmonary orifice or artery, from being
the most superficial, are on a higher key than any others. Though
they are so high as the whispered letter s, yet they range between
this and the whispered letter r. Murmurs originating in the as-
cending aorta where it approaches near to the sternum, are for the
same reason on almost as high a key.
Murmurs in the aortic orifice, being rather more deeply seated,
seldom rise higher than a whispered r, which is their average key,
and it is perhaps the most ordinary type of the sawing sound. M.
Bouillaud, however, (to whom I am indebted for the ingenious idea
1 This sometimes occurs after the exhibition of digitalis.
110 HOPE ON DISEASES OF THE HEART.
of representing sound by letters, and who has used s and r for this
purpose) thinks that s more truly represents the sawing sound.
Murmurs from aortic and pulmonic regurgitations, in conse-
quence of the currents being weaker, are generally two tones lower,
like whispering awe by inspiration, and the click of the valves,
when audible, may be represented by prefixing the letter /?, as in
the word paw.
Murmurs in the mitral valve, from being still more deeply seated,
are on the average four tones lower, like a whispered who: the
tone is somewhat elevated by a very strong current, as that of vio-
lent mitral regurgitation, and depressed by a feeble current, as that
producing diastolic murmurs.
Tricuspid murmurs are rather higher toned than mitral, because
less deeply seated.
It is scarcely necessary to explain that the depth or " hollo wness"
of murmurs is referable to remoteness and reverberation through
the chest. On this principle we should anticipate, and observation
proves, that a murmur is low-toned, not only from being deeply
seated, but also from being explored at a distance. Thus, an r
toned murmur generated in the semilunar valves, sounds as low
and remote as a whispered who if explored above the clavicles, an
inch on either side of the sternum or near the apex of the heart.
The principal use of this knowledge of the pitch or key of mur-
murs, is, to enable the anscultator to trace a murmur up to its
source — the point where it sounds loudest and seems nearest to his
ear ; for, without this ability, he can never succeed at particular
valvular diagnosis. Though the rules offered have required many
words for their development, they are, practically, so simple, that a
student, if well taught on three or four marked cases, can make
himself master of them in half an hour.
[Much of the ambiguity in the precise meaning of the terms used to ex-
press the cardiac murmurs, arises from losing sight of the type of the
sounds. Thus, as the saw when in movement produces a double rough
sound, so the term saw-sound should be restricted in its application to those
double rough sounds produced by the alternate motion of the heart. Rasp-
ing and filing being single sounds, should also be used to express single
sounds. — P.]
Musical murmurs. " This variety," says Laennec, c- occurs in
the arteries only, or at least I have never met with it in the heart."
This acute observer is mistaken in both these propositions. I shall
hereafter show (see Venous Murmurs) that the musical murmur
which he, M. Bouillaud. and all other writers, have ascribed to the
arteries, is really seated in the veins and is a twin phenomenon
with the continuous murmur. It is my present object to show that
the musical murmur is also a common occurrence in the heart, that
it may be a perfect note like whistling, cooing," or the mewing of a
kitten, and that it frequently co-exists or is blended with an ordi-
nary murmur. In the first edition of this work, I described the
case of a patient who applied to me for "a noise in the chest,"
PATHOLOGICAL PHENOMENA. Ill
which I found to be a musical note, audible at the distance of no
less than two feet. I added that, in a precisely similar case which
I found described by Dr. Elliotson in the Med. Gaz. of the week in
which I was writing, a very large and long vegetation existed in
the mitral valve. As I was writing in 1830, before the publication
of Dr. Elliotson's Lum. Lectures. I imagined that these were the
two first recorded cases of musical murmur in the heart ; but, on
reading his Lectures some years afterwards, 1 found reason to be-
lieve that he had observed the phenomenon at an earlier period
than myself; and I take the present opportunity of making this
acknowledgment, as I was not aware of the fact when the first edition
of the present work issued from the press. " 1 have," says Dr.
Elliotson, "heard it (the musical murmur) exactly resembling the
cooing of a dove — a variety not mentioned, I believe, by authors.
In one case it was so loud that I heard it when standing nearly a
foot from the patient. Three times have I heard this cooing sound."
He subjoins in a note, " A fourth instance has lately fallen under
my notice." This was, I doubt not, the one which I found in the
Med. Gaz.
Since I first heard the musical murmur in 1830, 1 have met with
fourteen or fifteen instances of it. In some it was an almost pure
note ; but in the majority it was blended with more or less of an
ordinary bellows-murmur : and in some of the latter the musical
note seems to have been coeval with the concomitant murmur,
while in others it commenced later, and in others again it ceased,
and was replaced by a murmur. Four cases are appended to illus-
trate these several varieties. Thus, in the interesting case of
Milton, the musical note was a clear tone like the oo in coo, swelling
and also rising a semitone in the middle, like the mew of a kitten.
It attended the second sound and proceeded from aortic regurgita-
tion. A feeble sighing murmur, occasioned by the refluent stream
within the ventricle, was heard down the tract of the ventricle, (but
not above the valves,) accompanying and prolonging the musical
note. In the case of V. Esq., there was a mixed musical and ordi-
nary murmur. In the case of Jones, the musical note was a broken
whistle, very loud and distinct, and it ultimately degenerated into
a loud sawing murmur. Its cause was mitral regurgitation. In
Tindal, on the contrary, an ordinary murmur took precedence, and
the musical note supervened at a later period. From these cases it
is clear that ordinary and musical murmurs are identical pheno-
mena resolvable into each other, the latter merely consisting of
finer and more even vibrations. To use an illustration which I
have employed for years (and which Bouillaud, who takes the same
view, has also employed) there is the same and no other difference
between the two sounds than between a blow and a whistle, as
performed by the lips; and no artifice is easier than that by which
we make the transition from the one to the other. That the medium
is liquid in one case and aeriform in the other, is unimportant ; for
M. Lagniard Latour has succeeded in producing musical notes by
the flow of liquids through apertures in tubes.
112 HOPE ON DISEASES OF THE HEART.
A musical murmur, therefore, indicates nothing more than an
ordinary one. I am inclined to think that it is most apt to result
from regurgitation. All my own cases, except two or three, have
been of this nature ; and the presentation of an edge to a stream, is
best calculated, according to Mr. Wheatstone, to produce musical
vibrations. Dr. Elliotson states that in all his cases, the cooing
accompanied the ventricular diastole, and was referable in situation
to the mitral valve ; but as he was then unacquainted with the re-
gurgitations, it is more than probable that he mistook the murmurs
of aortic regurgitation for mitral diastolic murmurs, — for I have
shown that murmurs from the latter cause are extremely rare. M.
Bouillaud (who is mistaken in supposing that "the musical whistle
of the heart had not yet (in 1835) been noticed by any one to
his knowledge") gives seven cases of this phenemenon, in one of
which it proceeded from mitral regurgitation, in another it accom-
panied the first sound in the aortic orifice, and respecting the re-
maining five, he is silent. (Traite, i. 168. His first case was in
1828.)
From all that has now been advanced respecting valvular mur-
murs, a subject on which I have dwelt with the desire to simplify
it by the introduction of fixed general rules, the following conclu-
sions may be deduced.
1. The ventricular systolic currents through contracted orifices,
from being stronger than the diastolic, produce louder murmurs.
2. Considerable contractions, of a rough, salient configuration,
whether osseous or not, produce the rough murmurs of sawing,
filing, or rasping, provided the current be that of the ventricular
systole, its diastolic currents being too feeble.
3. The pitch or key of murmurs is higher in proportion as they
are generated nearer the surface, and the currents producing them
are stronger ; and vice versa. Also, the key is lowered by distance,
independent of depth, from reverberation through the chest.
4. Musical murmurs indicate nothing more than ordinary mur-
murs.
5. Rough murmurs, and even loud and permanent bellows-mur-
murs, indicate organic disease.
6. Permanent murmurs from regurgitation necessarily indicate
organic lesions.
7. Continuous murmurs in the heart will probably be found to
indicate, sometimes organic disease attended with regurgitation out
of the aorta into the right ventricle or pulmonary artery ; sometimes
churning of a little serum between layers of rough lymph on the
pericardium ; and sometimes, probably, dilatation of the pulmonary
artery and compression of the vena innominata.
[The following lesions will cause different kinds of murmurs, which may
prove signs of those conditions.
a. Constriction, or projection in the arterial orifices, or valvular thicken-
ing in those parts, causes a murmur in the first, or systolic sound, similar to
filing, rasping, whizzing, or is gently blowing ; and if regurgitation exists,
PATHOLOGICAL PHENOMENA. 113
the second sound may be similarly changed, and if rough, a double, grating
or saw sound will be heard.
b. Constriction, or impediment in the auriculo-ventricular orifices causing
a blowing, rough or rasping murmur in the first sound during the ventricular
systole. A regurgitating murmur may exist during the diastole of the ven-
tricle, and thus form a double sound: but the latter murmur is rarely pre-
sented.
c. Imperfect closure of the arterial valves arising from thickening, or
from ulceration, or from adhesion to the sides of the arteries, (producing in
some cases permanent patency,) causes various roughened sounds in the
first, which, if not too intense, is followed by a rough second sound ; for if
the first abnormal sound be very great, it masks the sound produced by re-
gurgitation.
d. Imperfect closure of the auriculo-ventricular orifices caused by organic
changes of the valves, or by shortening of the columnar carneae, producing
permanent patency, gives rise to similar sounds, which are heard principally,
(as stated in b:) during the first sound.
e. Dilata»ion of the aorta or pulmonary artery near the cardiac orifices, ac-
companied by contraction beyond, causes a blowing or roughened murmur
with the first sound.
/. An unnatural opening from the aorta near its commencement into a
sac or abnormal cavity causes a whizzing, blowing or bellows murmur, vary-
ing in intensity, in the first sound.
g. Endocarditis, by producing thickening in the valve, by the formation
of coagula, dec, gives rise to various murmurs which are generally bellows
sounds, but which vary with the force of the circulation : in some cases the
abnormal sounds are extremely rough, in others, barely appreciable. The
bellows murmur when arising from endocarditis, is generally observed in
the first sound.
All the abnormal murmurs have a direct relation to theforce of the heart's
action, and their character is often changed by the varying degrees of the
arterial circulation. Thus, the bellows, or blowing murmur may become
whizzing, rasping, grating; and the musical become of a higher pitch. Fre-
quently, as has been previously mentioned, slight obstacles may exist at the
cardiac orifices, and yet, no abnormal sound be produced, whilst that organ
remains tranquil; but excitement from any cause, by producing increased
force of the circulation, will instantly develope an abnormal murmur. — P.
"The quantity of blood may also modify these sounds: when excessive,
it increases and prolongs them; when very defective, and, accompanied by
an excited action of the heart, it may make them loud and short. Even the
quality of the blood may influence the sounds; for a thin watery fluid is
more readily thrown into sonorous vibrations than one of a richer, more vis-
cid character; and this is one reason why murmurs are so easily produced
in chlorotic and anemic subjects. In these the slightest pressure of the ste-
thoscope on the carotid arteries in the neck is enough to cause a loud continu-
ous, or remittent whizzing, to which the French have given the name of
" bruit de diable," from its resemblance to the noise of a toy called a "dia-
ble."—C. J.B. Williams's Lectures.]— P.
It has been explained above that a knowledge of the key orpitch
of murmurs assists the auscultator in tracing them up to their
sources, or, in other words, up to the situations in which they are
most audible. It remains to be explained what these situations are
in reference to the several valves, and this constitutes beyorfd com-
parison the most important essential to particular valvular diag-
nosis.
9— c 8 hope
114 HOPE ON DISEASES OF THE HEART,
Situation in which Murmurs of the respective Valves are most
audible.
Authors had not pointed out these situations with any degree of
accuracy previous to the first edition of this work : nor was it pos-
sible for them to do so; for, as they were unacquainted with the
regurgitations, they could not know whether a murmur with either
sound was seated in an arterial, or in an auricular orifice. Dr.
Elliotson, indeed, who had heard of the regurgitations, but had no
practical acquaintance with them, attempted, in his Lum. Lectures
in 1830, to define the situations in question; but the subjoined
quotation will at once evince his total failure, and the necessity for
more precise rules on the subject. 1 In the appendix to the second
edition of this work, I made corrections and additions to. my previ-
ous rules, being greatly assisted by the strong light reflected on the
subject by my experiments demonstrating the causes of the natural
sounds. I am now enabled to offer a code of rules of so simple and
obvious a nature that, with the assistance of the diagram Fig. 4, I
have found students acquire them in the course of a few minutes.
Murmurs seated in the semilunar valves are best heard imme-
diately over those valves, (that is, on the sternum, opposite to the
inferior margin of the third ribs when the patient is horizontal, and
a little lower when he is erect,) and thence for about two inches
upwards, along the diverging courses of the aorta alid pulmonary
artery respectively. A distinct murmur high up the aorta proceeds
from the aortic valves, as a pulmonic murmur is only feebly and
indistinctly transmitted in that direction. It may be known that
the murmur proceeds from the aortic valves rather than from the
diseased ascending aorta itself, by its key not being higher than a
whispered r, whereas a murmur from the aorta itself is commonly
a tone or two higher, approaching towards an s, and also seems
much nearer and more superficial.
A distinct murmur high up the pulmonary artery proceeds from
the pulmonic valves, as an aortic murmur is only feebly and indis-
1 "If the impediment is in the left ventricle, at the mouth of the aorta, it"
(the murmur) " is loudest at the cartilages of the ribs to the left of the
sternum; if in the right ventricle, at the mouth of the pulmonary artery, it
is loudest at the sternum and to the right. The sound is often so loud, that
it prevents the natural sound of the auricles from being distinctly percepti-
ble till the ear or stethoscope is removed from the region of the ventricles,
higher, to the region of the auricles."
" When the impediment is at either of the auriculo-ventricular openings,
the morbid sound is heard at the moment of the auricular contraction," (i. e.
with the second sound,) "and is generally loudest at the superior part of
the cardiac region. It is loudest "at the cartilages of the left ribs, when the
left aurfculo-ventricular opening is narrowed ; loudest at the sternum and
to the right, when the narrowing is at the right auriculo-ventricular open-
ing." Nothing can be more erroneous, contradictory, and confused than this
account. The subject was, in fact, necessarily inexplicable till the regurgi-
tations and immediate sources of the murmurs became known.
PATHOLOGICAL PHENOMENA. 115
tinctly transmitted in that direction. The pulmonic murmur,
\vhether seated in the valves or in the pulmonary artery itself, (as
when dilated,) always sounds near and superficial, provided the
current be sufficiently strong ; because the valves and artery are
close to the surface, the valves being not only in front of the aortic
valves, but half an inch higher up. A murmur in the pulmonic
orifice is more audible down the tract of the right ventricle than of
the left — which is a corroborative circumstance.
Thus, by listening high up the aorta and pulmonary artery, it
is easily ascertained in which vessel the murmur is seated. This
rule will even apply to semilunar regurgitations, notwithstanding
that their murmurs are weaker and not so well transmitted up the
vessels in consequence of the current setting out of them into the
ventricles. Further rules for distinguishing these regurgitations
have been offered at p. 99. There is a further and most important
advantage in exploring murmurs of the semilunar valves high up
the vessels : namely, that in these situations murmurs of the auri-
cular valves are, from their remoteness, either wholly inaudible or
very obscure : although, therefore, an auricular murmur should
co-exist, it would not prevent the anscultator from deciding that a
loud and near sounding murmur, heard high up the vessels, was
generated in or above the arterial orifices.
Murmurs seated in the auricular valves are best heard at that
part of the precordial region where, from the heart being in con-
tact with the walls of the chest, there is dulness on percussion — in
short, about the apex ; for the murmur is best conducted [by the
columnas corneag] to the surface through a solid medium. The
upper and left side of the dull portion, being nearest to the mitral
valve, is the best point for exploring its murmurs; and this point
will generally be found situated about the fifth rib or subjacent in-
tercostal space, and a little to the right of the nipple : in females, it
is under the mamma when pretty well raised, and a little to the
right of its centre. If the impulse of the heart be perceptible, there
is no better guide than this to the situation in question. The ans-
cultator has only to place his stethoscope about an inch above the
spot where the apex impinges.
The upper and right side of the dull portion, being nearest to
the tricuspid valve, is the best point for exploring the murmurs of
this valve; and the point will generally be found on or near the
sternum, at the same level as on the opposite side. If, in making
these explorations of either valve, the stethoscope be placed half
over the dull portion and half over the thin resonant edge of the
lunof, the object will be sufficiently answered.
There is a further, and most important advantage in exploring
murmurs of the auricular orifices in these low situations: namely,
that the murmurs sound so near and distinct as to preclude the idea
of their being generated in the arterial orifices, the murmurs of
which always sound remote and obscure when explored near the
apex of the heart. The only source of fallacy is in the case of
8*
116 HOPE ON DISEASES OF THE HEART.
regurgitation through the semilunar valves on either side of the
heart ; for, here, the murmur descends down the ventricle with the
refluent stream. It has been shown that this was the fallacy which
deceived Laennec, Bouillaud, Elliotson, and all others who have
believed in the frequency of diastolic murmurs of the auricular
valves; yet it is obviated with the utmost ease by attention to the
fact that the regurgitant murmur increases progressively on ascend-
ing from near the apex to the semilunar valves, and that it is audi-
ble above them ; whereas, the auricular diastolic murmur decreases
in the same progression and is totally inaudible above them.
When both the semilunar and the auricular valves are diseased,
it is perfectly easy to ascertain this by observing, according to the
above rules together with those for the pitch of murmurs, that there
are two distinct sources of murmur.
When two murmurs are seated in the same orifice, this is readily
ascertained by tracing them up to the single source, and noticing
that one attends the first, and the other the second sound.
In making a valvular diagnosis, it is necessary to keep the ringer
constantly on the pulse, in order to distinguish the first and second
sounds, with their murmurs, from each other. If the radial pulse
be much later than the first sound, the carotid should be felt, as its
synchronism is more perfect. It is necessary to reiterate these ob-
vious rules, because, from inadvertence, they are habitually neglect-
ed by novices.
In exploring a delicate murmur, the auscultator should hold his
own breath, [and request the patient to inspire very fully, then free
the air from the lungs by expiration, cease respiration, and lean
forward. The patient by these means will be enabled to hold his
breath for some time, and the heart, will be thrown more upon the
parietes of the chest. — P.] The utmost attainable silence should reign
in the room. If an expert auscultator can hear in a noise, it is
because he catches the sound during the momentary intervals of
silence, but the learner must not expect to accomplish this. He
should always endeavour to keep his head erect and his neck
straight, otherwise cerebral congestion will impair the nicety of his
hearing. Many vaunt the superiority of the naked ear over the
stethoscope. The writer has not found himself inferior to others
in the use of the naked ear, but he may perhaps be permitted to say
that he possesses far more delicacy with the cylinder than without
it ; whence he suspects that those who entertain an opposite opinion,
unconsciously labour under some special disadvantage. He has
observed the disadvantages to be principally of three kinds : 1. The
inexpert scarcely ever apply the instrument, air-tightly ; 2. The
stethoscope is a bad one — the ear-piece nearly flat, the joints loose,
the cone false and the bore unpolished : 1 3. The auscultator is dull
1 Finding so many bad instruments in use, in 1833 I taught a clever turner
(Grumbridge, 42 Poland street, Oxford street) to make stethoscopes, and he
now makes a greater number, and incomparably better instruments, than per-
haps any one in the metropolis, or the kingdom, — completely avoiding all the
PATHOLOGICAL PHENOMENA. 117
of hearing. An eminent practitioner and even a teacher of auscul-
tation with respect to the lungs, remarked to me that he did not
believe that anything had yet been done to unravel the murmurs
of the heart. I felt surprised. My surprise ceased when he sub-
joined that "for his own part he had never yet been able to distin-
guish the two natural sounds of the heart !"
SECTION III. — Murmur from Hypertrophy with Dilatation, and its Mechanism.
In a case which presented itself to me in 1S25 (Med. Gaz., Sept.
5, 1829, p. 420), I was led to notice that murmur was produced by
a disproportion between the cavities and the orifices, consequent on
enlargement of the former. Laennec also mentions bellows-mur-
mur from hypertrophy or dilatation. (Traite, ii. p. 441, second edi-
tion.) In the former editions, I represented it to be of frequent oc-
currence in the aortic orifice and with the first sound, in cases of
great hypertrophy with dilatation ; but I have subsequently found
that it is restricted to those cases almost exclusively in which there
is anosmia, a state very apt to supervene in the advanced stages of
organic disease of the heart, and which will be shown in the ensu-
ing section to be the principal cause of murmurs independent of
organic impediments. The changed form of the ventricle in hyper-
trophy with dilatation probably co-operates in the production of
the murmur; for, as the cavity is more spherical than natural, and
its artery consequently rises more abruptly with respect to its in-
ternal surface, the currents of blood reflected from its sides meet in
defects specified in the text. The two kinds I recommend, and for which he
has my models, are, the long, thick one without a joint, for home and hos-
pital practice (price 4s); and the long, thin one with a screw-joint in the
middle, for carrying in the pocket (price 7s. 6d). I w*ould dissuade the
student from accustoming himself to a short stethoscope; first, because it
possesses little if any advantage over the long one ; secondly, because in
private practice a long one is more agreeable to both parties on the score of
delicacy; and thirdly, because a short one is exceedingly inconvenient in
reaching over large beds, &c, and is often the cause of a slovenly explora-
tion. The only innovation which I have ventured to make in the construc-
tion of the stethoscope, consists in a deeper excavation, larger circumference,
and a more bevelled or rounded edge of the ear-piece, than was employed
by Laennec. Such an ear-piece suits almost every one on the first trial.
Its advantage consists in its being air-tight when applied, and in its bringing
a large surface of the ear into solid contact with the cranium ; for, as Dr.
Cowan has ably shown, the solids as well as the meatus externus conduct
the sound.
[The flexible stethoscope covered with gum-elastic and silk, eighteen
inches long, the ends formed of block tin, the hollow cone for the reception
of the sound, an inch in diameter, I find to be an instrument of indispensa-
ble utility in fixing the precise situation of the abnormal murmurs. Much
uncertainty attends the use of the ordinary stethoscope, inasmuch as the
parietes of the chest convey sounds, so that a murmur generated in one
portion of the chest may be transmitted by a rib, &c, to a distinct point;
with the flexible tube, however, this difficulty is overcome. — P.]
118 HOPE ON DISEASES OF THE HEART.
the orifice at more obtuse angles, and thus, by their collision, not
only give rise to the murmur, but impede each other's passage into
the vessel. For the latter reason, the pulse is sometimes small and
weak, when the impulse of the heart is violent, — a paradox with
which authors have been much perplexed.
[This feebleness of the pulse may also arise from regurgitation through
the mitral valve. — P.]
SECTION IV. — Murmurs in the Heart and Arteries independent of Organic Disease,
Before proceeding to assign the cause of this phenomenon, it is
necessary to be agreed as to the circumstances under which it
occurs. The account which Laennec gives of it, and of the con-
comitant phenomena purring, tremour (fremissement cataire), and
(what I conceive to be merely a less degree of the same) thrilling
(fremissement) of the arteries, does not accord with my own obser-
vation, and it involves several inconsistencies, which render the
phenomena equally inexplicable on his own and on every other
theory. To question anything which Laennec explicitly states as
a fact, is hazardous : the more I have studied his works, the more
have I become sensible of this, and felt astonished at the wonderful
accuracy of his powers of observation. With respect to the subject
before us, however, it is both apparent from the statements in his
treatise, and well known to those who were acquainted with him,
that he had not satisfied his own mind : that he was conscious of
incongruities which he could not reconcile, and of difficulties which
he was unable to surmount. With less presumption, therefore,
may I enter on an investigation which his genius can only be said
to have left incomplete; and I do it with more satisfaction, as I
have to advocate the cause of auscultation against its great inventor,
and to show that the doctrines broached in his first edition respect-
ing bellows-murmur as a sign of valvular disease, were not, as he
imagined, invalidated by the more extended knowledge of the na-
ture of this phenomenon which he supposed himself to have ac-
quired at a later period.
"The bellows-murmur," says Laennec, "may accompany the
diastole of the heart and that of the arteries, and it is connected
with them in such a manner as to replace and entirely annihilate
their natural sound (i. e. the second) ; so that, at each diastole, the
ventricle, the auricle, or the artery in which the phenomenon takes
place, yields a distinct sound of a puff of the bellows, the noise of
which ceases during the systole." (De I'Auscult. t. ii. p. 422.)
This account is clearly inconsistent with itself. It is certain
that the murmur in question takes place synchronously in the heart
and arteries : it cannot, therefore, take place during the diastole of
both, as the diastole of the one coincides with the systole of the
other. The error consists, as I shall presently'show, in saying that
the murmur coincides with the diastole of the ventricles, instead of
with the systole. Granting, for a moment, that the murmur does.
PATHOLOGICAL PHENOMENA. 119
as Laennec imagines, accompany the diastolic movements of the
ventricles, this view is irreconcilable with his explanation of the
cause of the phenomena ; for, having disavowed his belief that the
cause is connected with the motions of the fluid (De l'Auscult. torn,
ii. p. 429), he says, "The perfect similitude of the intermittent
muscular sound (bruit musculaire) and of the bellows-murmur of
the heart and arteries, appears to me entirely to decide the questions
which 1 have above proposed on the nature of this murmur, and to
prove that it is referable to a real spasmodic contraction, whether
of the heart or of the arteries. The possibility of a spasm of the
heart needs not to be demonstrated, since that organ is muscular.
With respect to the arteries, the circular fibres which compose their
middle coat appear to announce a tissue endued with the faculty
of contraction/' (Ibid. p. 440.) Now, if spasmodic contraction be
the cause of the bellows-murmur, this murmur cannot take place
during the diastole of the heart, which, according to the best au-
thorities, is an act, not of contraction, but of relaxation. Neither
will spasmodic contraction account for the bellows-murmur in the
arteries ; for the murmur takes place during their diastole, and not
during their systole, as Laennec's theory supposes. Apparently
conscious of this inconsistency, he endeavours to reconcile it by
saying that the murmur occurs while the artery is in the act of
turning from its diastolic to its systolic state. There is, however,
no doubt that it occurs while the artery is in the progress of dilata-
tion.
The cause of the confusion and inconsistency into which Laen-
nec has fallen, is evidently that to which I have so often adverted
— his unacquaintance with the regurgitations. Thus, the quota-
tion from this author at p. 118, is manifestly a description of semi-
lunar regurgitation. That he should have overlooked this regurgi-
tation, is not surprising, for two reasons: 1, because the organic
lesion of the valves producing it is often slight, — nay, sometimes
totally absent ; for the regurgitation may result from mere dilata-
tion of the orifice: 2, because his attention in the post-mortem ex-
amination was wholly directed to the auriculo-ventricular valves,
disease of which he believed to be the only organic source of mur-
murs with the second sound. Detecting no organic disease in these
valves, it is not wonderful that he should ascribe the murmur to
inorganic causes : nor is it wonderful that the frequency of these
supposed inorganic murmurs should have made a strong impres-
sion on his mind; for I have already shown that semilunar regur-
gitation is one of the most common forms of valvular disease. In
studying genuine inorganic murmurs, therefore, we must carefully
exclude this source of fallacy.
Respecting the purring tremour (fremissement cataire) of arteries,
Laennec avows that, notwithstanding all the pains he has taken for
the purpose, he has not been able to discover any satisfactory rea-
son for the phenomenon. (De l'Auscult. torn. ii. p. 452.) Nor is this
surprising: for having attributed the twin and concomitant pheno-
120 HOPE ON DISEASES OF THE HEART.
menon, bellows-murmur, to spasm, — a state tending to place an
artery in a state of constriction and immobility, rather than of
vibration, he has no other physical resource remaining, by which
to explain the purring tremour. He accordingly yields to the dif-
ficulty; for it is little more than a substitution of words for ideas,
to say, " it is at least extremely probable that the purring tremour
depends upon a particular modification of the nervous action"
(innervation) (ibid. p. 453); and that "the three phenomena, bel-
lows-murmur, purring tremour, and the thrilling pulse, are attribu-
table to different, though analogous, modifications of the action of
the arteries and the heart, and that the one cannot be regarded as a
more or less intense degree of the other." (ii. p. 767.) M. Bouil-
laud has more recently made similar strictures on Laennec. " Hav-
ing," says he (Traite, i. 229, 1835), -'made vain efforts to untie this
sort of Gordian knot, like another Alexander he has cut it. In
twenty places of his work, we see him repeat the same profession
of faith : there, he says that the different varieties of arterial bel-
lows-murmur are due to a peculiar vital state of the arteries (ii. p.
429); here, that they are due to a spasm of the arteries (p. 441 —
443); elsewhere, that they depend on a simple modificatio?i of the
innervation — an anomaly of the nervous influx." (p. 763.)
Having thus endeavoured to present a brief sketch of a subject,
which, from its obscurity, has in general occupied several chapters,
I proceed to oiler an explanation of the inorganic murmurs, tre-
mours, and thrills in question on a different principle; and I trust
to show that it is possible to surmount the physical difficulties of
which even M. Bouillaud complains, and which have prevented
him, no less than Laennec, from bringing the subject to a satisfac-
tory conclusion.
As my own experience does not accord with that of Laennec as
to which motions of the heart are accompanied by the murmur, it
is necessary to premise that I have found it accompany the systole
of the ventricles exclusively. In the arteries, it coincides with their
diastole, which is synchronous with the ventricular systole. The
purring tremour occurs at the same moment and is a result of the
same cause. The arterial thrill is nothing more than a less degree
of the purring tremour.
Both by experimental and pathological evidence, I am led to
believe that the murmurs and tremours, as well in the heart as in
the arteries, are occasioned by modifications in the motion of the
fluid, occasioning increased friction and vibration. To establish
this point, it is necessary to prove, 1, that liquids permeating tubes,
do occasion murmurs and tremours : 2, that, in the living subject,
modifications in the motion of the blood calculated to elicit mur-
murs and tremours, do take place under the circumstances in which
such murmurs and tremours actually occur: 3, that the explana-
tion applies equally, whatever be the circumstances under which
the murmurs and tremours occur.
1. That a bellows sound is produced by the transmission of a
PATHOLOGICAL PHENOMENA. 121
fluid, without any intermixture of air, through a tube, though
questioned by Laennec (torn. ii. p. 763—4, note), is a fact too easy
of demonstration to require discussion. Having just returned from
a repetition of the experiment, — one which I have frequently per-
formed, I find the rushing murmur so distinct and close to the ear,
as to preclude the idea of a fallacy from the movement of a piston
or any other cause : 1 find the sound to vary in intensity according
to the velocity with which the fluid is propelled, to be increased by
bending the tube at an angle, and to be still further increased, but
also modified, by the admission of air — becoming of a rattling na-
ture, totally different from any sound heard in the heart or arteries.
A thrill or vibration, perceptible to the hand, attends the murmur
provided the motion of the fluid be sufficiently rapid, or provided,
with a less rapid current, the interior of the tube be rough or ob-
structed. The vibration is best felt in thin metallic tubes (from the
superior vibratory power of metals), and in yielding tubes, like the
leather pipe of a steam engine; and the thrill in the latter is in-
creased by locally compressing or indenting it. These experiments
have been performed with the same results by M. Pelletan, profes-
sor of medical physics to the Faculty of Paris ; by Dr. Spittal on
leaden pipes {Med. Gaz. Aug. 3, 1833); by M. Piorry {Percuss.
Med. et Archiv. Gener. de Med.)\ and by MM. Bouillaud and Donne.
(Traite du Coeur par Bouillaud, i. 205.) The three latter gentle-
men have even produced the murmur by injecting water into the
arteries of the dead subject, and have thus corrected an error into
which M. Pelletan had fallen ; namely, that vessels with a smooth
interior did not yield the murmur.
What experiment thus proves, the principles of hydraulics
would lead us to anticipate. It is a fact, established by the inves-
tigations of Newton, De Buat, Bernoulli d'Alembert, Robison, Ven-
turi, Dr. Young, and others, that the progress of fluids through
pipes, however smooth, is retarded by friction against their interior;
and that the retardation is increased by all projections, irregulari-
ties, and sudden bends; for the fluid, striking against these, forms
reverberations and eddies, which impede its current as effectually
as solid obstacles. The friction increases with the increase of velo-
city, and, beyond a certain point, it increases in a much more than
simple ratio. Thus, if a steam engine often horse power will pro-
pel a vessel ten miles an hour, one of a hundred would not suffice
to propel it twenty. Now the friction. — in other words, the colli-
sion of the particles of fluid against the sides of the vessels and
against each other, by producing vibrations of a certain rate of
rapidity, is the cause of the sound; and these two phenomena, the
friction and the murmur, are, consequently, in the direct ratio of
each other. Hence it appears that the murmur is produced in
strict conformity with the general axiom, that the particles of all
bodies, when thrown into sufficient vibration, generate sound. I
have already shown that Dr. Corrigan's supposed new theory of
murmurs is partly incorrect, and that, where correct, it is identical
122 HOPE ON DISEASES OF THE HEART.
with my own, which he has misunderstood and imperfectly repre-
sented. (Dub. Jour. vol. x. p. 177.) His current like motion is no-
thing more than the "reverberations and eddies," the " preternatural
commotion," the "arterial vibration," described above and in other
parts of this work, as attending the production of murmurs. These
phenomena, together with the lax arterial coats, the coats of unfilled
arteries, have never been more strikingly exemplified than by the
experiments subsequently detailed under the ensuing head.
["In fact, all these murmurs are produced by the passage of liquids
through solid tubes or apertures in the same manner as analogous sounds
are produced by the passage of air through pipes or holes of different kinds.
They are the music of water-instruments, as the latter are the music of
wind-instruments. There are only these differences between them, that
liquids being more sluggish than air, are less susceptible of the sudden mo-
tions which constitute sonorous vibration, and not differing so much in
density from the solids in which they move, liquids will have little of those
reflected or echoed vibrations which increase and modify the sounds pro-
duced in air-filled tubes. Holding in mind these qualifications, we may ex-
plain the murmurs heard in the heart and arteries by referring to parallel
instances of the tones of wind-instruments; nay, we may find the parallel
phenomena in the rhonchi, respiratory, and vocal sounds of that most com-
plete and diversified wind-instrument, the wind-pipe and its branches. Like
in these, there are varieties of sound, in generating which, the solids and
the current have different shares; thus in the grating, sawing and stronger
droning murmurs, the vibrating resistance of the solid is chiefly concerned;
and its vibrations are transmitted to the adjoining parts as well as to the
current, so as to produce in them a thrill which may sometimes be felt by
the hand. Being in the rhythm of the heart's motion, this thrill resembles
that felt on the back of a purring cat, whence Laennec called it the ' fre-
missement cataire.' These have their parallels in the sonorous rhonchus,
in reed instruments, and in those imitations of these murmurs which we can
produce by forcibly breathing through the nearly closed teeth, tongue, and
lips, which in like manner communicate a sensible vibration to the solids,
as in ringing the letter B, in a whisper. Again, in the blowing, hissing,
whistling and cooing murmurs, the vibrations are more those of the current
reflected by the solid, in the manner of cavernous breathing, the sibilant
rhonchus, blowing, or whistling with the mouth, or of the flute class of musi-
cal instruments. Here there are no perceptible vibrations in the solids;
they are less actively concerned in the production of these sounds, which
are rather transmitted in the direction of the current." (Lectures on the
Chest, by C. J. B. Williams.)—?.]
2. It is next to be proved that, when murmurs in the heart and
arteries do occur independent of organic disease, there is an increase
of friction, dependent on a modification of the motion of the blood,
to account for them.
Being engaged with Dr. Marshal Hall in a series of experiments
on the effects of loss of blood, &c. — a subject for the elucidation of
which the profession is much indebted to that gentleman, we took
the opportunity of studying the stethoscopic phenomena of the cir-
culation under all the circumstances of collapse, reaction, &c.
Eight or ten dogs were blooded more or less frequently, from
oncelo ten or twelve times, and at intervals varying from twenty-
four to seventy-two hours. The results were, that, on the day
PATHOLOGICAL PHENOMENA. 123
following the first or second abstraction of blood to the amount of
eight or ten ounces, the systolic sound of the heart, previously loud
and clear, became attended with a whizzing or sawing murmur,
the impulse increased and became unusually smart or abrupt, and
the pulse became quick and jerking (the pulse of unfilled arteries),
with a thrill and a throbbing, perceptible over the whole body.
These phenomena increased up to the fourth or fifth bleeding, when
they appeared to attain their maximum, the sawing sound being
extremely loud, the impulse and pulse violently jerking and bound-
ing, the arterial thrill or purring tremour excessive, and the throb-
bing perceptible not only when the finger was placed on an artery,
but when the hand grasped a large surface of the body. A hissing
bellows-murmur was, moreover, distinctly heard, when the stetho-
scope was placed over any considerable artery, as the femoral or
carotid. The pulse at this time generally beat from 150 to 190
per minute, its natural standard being about 120.
The phenomena underwent the following changes in corre-
spondence with changes in the circumstances. The animals being
extremely nervous and irritable, the pulse was instantly accelerated
ten or fifteen beats per minute by the slightest excitement, as that
of being moved or startled ; and the murmur and jerk sustained, in
consequence, a remarkable increase.
After reiterated venesections the pulse became small and weak;
but, so long as it remained jerking, the murmur continued, though
not so loud as previously.
If venesection was omitted for three or four days, reaction sub-
sided ; and in proportion as the pulse and impulse became softer,
though without a loss of real strength and fulness, the murmur,
both of the heart and arteries, the purring tremour, the general
throbbing, and the nervous irritability, gradually disappeared.
If, during the full prevalence of all the phenomena, the animal
was bled to the approach of syncope, the pulse and beats of the
heart, reduced to about one hundred per minute, became feeble and
soft, and at the same time lost all murmur and thrill ; but, in the
course of from fifteen to thirty minutes, reaction was re-established,
and all the symptoms recurred.
If the animal was held erect by the forelegs, a posture which,
either by diminishing the afflux of blood to the brain, or by ob-
structing the circulation through the heart and lungs, caused the
gradual supervention of syncope, the pulse became slow, soft and
feeble, and the murmur and thrill were suspended; but they were
promptly restored to their former state when the animal was placed
on its legs.
From these experiments it may be concluded, a. That diminution
and attenuation of the blood are circumstances eminently favourable
to the production of inorganic murmurs: — the diminution, because,
as the weight of the blood is diminished, the fluid can more easily
be propelled with velocity, and because the diminished tension of
the arteries allows more latitude for sonorous vibration both of
124 HOPE ON DISEASES OF THE HEART.
their walls and of the blood: the attenuation, because the particles,
having lost a proportion of their lubricity, are better calculated for
rapid motion, and consequently for the production of murmur and
vibration by collision against each other and against the walls c f
the containing vessel. This attenuation (the existence of which
was strikingly displayed in some of the above experiments by the
crassamentum bein^ reduced to a very small fraction, — one sixth
to one twelfth, for instance, of the serum) is not confined to cases
of excessive loss of blood, but exists also in an immense proportion,
if not the whole, of the reputed nervous cases which present bellows-
murmur, b. That the murmurs and tremours are partly depend-
ent on the abruptness of the heart's contraction, or. more rigidly
speaking, on the velocity with which the blood is propelled in con-
sequence of that abruptness, — a velocity which implies an augmen-
tation of friction, and consequently of arterial vibration. That an
increase of the velocity, independent of an increase of the real force
of the heart's contraction, suffices, under these circumstances, to
excite the phenomena, is proved by their existing when the pulse
was small and weak; provided it was jerking, and by their increas-
ing when, with the same small and weak pulse, the beat of the
heart was accelerated by startling the animal. I conceive the pri-
mary moving cause, then, to reside in the heart, and not in the
arteries, because the action of the latter was always in exact pro-
portion to that of the former.
To recapitulate: the physical circumstances usually attending
inorganic murmurs in the heart and arteries are, 1, attenuation of
the blood: 2, unfilled arteries permitting unusual vibration of their
walls and a rippling current: 3, a certain velocity of the current
occasioned by abrupt contractions of the heart.1 I do not see why,
1 Dr. Corrigaa has not attached sufficient weight to the essential circum-
stance of a certain degree of velocity, — an error into which he appears to
have been betrayed by the inaccuracy of the two leading facts on which he
founds his theory. 1. In permanent patency of the aorta valves (regurgita-
tion through which, unfills the arteries) he says that the murmur with the
first sound uis generally very loud" and that "the theory of increased ve-
locity will not apply to it, ./or the sound exists without it, and each indivi-
dual contraction of the ventricle of the heart in this disease is not more' rapid,
but indeed generally slower than in health, whether examined by the stetho-
scope or by the pulse, which is full and rises without any jerk under the
finger" {Dublin Jour. vol. x. p. 185 — 6.) Now, I beg to deny the fact that,
in this disease, murmur attends the first sound. Before me lie nine case::
in which it was absent, and I have never known an instance in which Jt
was present, unless the circulation was accelerated or there was more or less
obstruction in the aortic orifice. It is with the second sound that the mur-
mur takes place — and invariably : not " in some cases" only, as he states.
The pulse too, when the regurgitation is at all considerable, is invariably
and pre-eminently jerking : it is, par excellence, the pulse of unfilled arteries.
2. Dr. Corrigan states, " that of all the lesions with which bruit de soufflet
is connected, it is in contraction of the auricular valves that the sound is
most constant." (Ibid. p. 1S2.) I have already shown at p. 103 that the re-
verse is the case — that the murmur with the second sound, to which he refers,
PATHOLOGICAL PHENOMENA. 125
when the three preceding causes are in action, a fourth (though I
have not seen it noticed by authors) is not brought into co-opera-
tion : namely, a disturbance of the current at every point where a
branch springs from an arterial trunk. This disturbance neces-
sarily and invariably takes place when rigid tubes are the subject
of experiment; and, though the elastic compression of tensely filled
arteries in healthy subjects may5 in a great measure, prevent it by
limiting the vibratory power both of the arterial walls and the
blood, such would not be the case in arteries lax from anaemia. I
merely submit this as a suggestion, but would meanwhile remark
that the arteries in which inorganic or anaemic murmurs are of
I lost common occurrence, happen to be precisely those from which
several large branches arise within a small space: namely, the sub-
clavians, carotids, and abdominal aorta.
Before closing this division of the subject, I am induced to trans-
cribe the following interesting case in the human subject, related
by M. Bouillaud in corroboration of the preceding experiments on
dogs. "I was summoned, says he, on Aug. 21, 1834, to see, with
the surgeon-major of the third Lancers, the son of a chef d'escadron,
a3t. 16, who, after a leech-bite, had lost an enormous quantity of
florid blood very probably furnished by a small divided artery.
Syncope was imminent: lips and face colourless, eyes turned up
and livid, general coldness, long sighing inspirations, pulse exceed-
ingly quick and weak, <fcc. On listening to the beats of the heart,
which were feeble but very abrupt and frequent so as scarcely to
admit of being counted. I heard a clear, smart bellows-murmur, like
the puff with which one blows out a candle. I made the surgeon-
major and assistant-major attest the phenomena. I was of opinion
that the murmur depended solely on the fainting and anaemic state,
during which, from the hurried palpitation of the heart, the small
is seldom present and always weak, and that the cause of this is, simply,
deficient velocity and strength of the current.
It may be incidentally remarked that Dr. Corrigan announced "Perma-
nent patency of the mouth of the aorta" as a new disease, in the Edin. Med.
and Surg. Jour, for 1S32: it was, however, described in this work published
in December 1831, and I had discovered it several years previously, and
taught it, and regurgitations in general, both in St. Bartholomew's Hosp. and
La Charite, Paris, as early as 1826. M. Bouillaud, who remarks upon Dr.
Corrigan's "pretended** new disease, does not say who was the discoverer,
but seems to allude to M. Guyot, interne to M. Rayer in 1834. (Traite, i.
225.) The above dates settle the question.
Though Dr. Corrigan's theory is, as above shown, partly incorrect, and,
where true, only an iteration of my own, M. Bouillaud is totally wrong in
supposing that his own arguments derived from Dr. Corrigan's error respect-
ing aortic regurgitations, are conclusive against the doctrine that lax arterial
walls and a consequently rippling current contribute to the production of
arterial murmurs. (Traite, i. p. 223.) This is one, amongst other reasons
presently to be explained, why he has given so singularly unsatisfactory an
explanation of the murmurs in question — sometimes confining himself to
" donnees fort generales," and sometimes avowing his total ignorance. (Ibid,
p. 227—8.)
126 HOPE ON DISEASES OF THE HEART.
column of blood contained in the ventricles was expelled if not
with much force, at least with a sort of convulsive rapidity. I re-
visited the patient on the following day at the same hour: the
hemorrhage had ceased for more than twenty hours. There did
not exist a trace of the murmur, which, according to the surgeon-
major's account, had completely disappeared ever since the prece-
ding evening." M. Bouillaud adds that the patient had no organic
disease of the heart. (Traite, i. p. 180.)
We now come to the third branch of the subject : namely, to
show —
3. That the explanation applies equally, whatever be the cir-
cumstances under which the sounds occur : viz. that there is an
increase of friction dependent on a modified motion of the blood.
a. A murmur resembling the slightest and shortest whiff with
which we blow out a candle, may be factitiously produced in any
considerable artery, as the carotid, subclavian, humeral, femoral or
tibial, by slightly pressing it with the end of the finger or with the
edge of the stethoscope while we listen. Here, the indentation im-
pressed on the artery causes a local obstruction, which breaks the
current, increases the friction, and causes sonorous vibrations both
of the blood and the lax walls below. Though the effect takes
place in healthy subjects, it is much greater in the anaemic with
palpitation and a jerking pulse, and in cases of regurgitation
through the aortic valves — a state also attended with unfilled arte-
ries and a remarkably jerking pulse: and the reason why the mur-
mur is louder and the thrill stronger in these two classes of cases,
is (in addition to attenuation of the blood in the one class) that the
fluid is shot through the stricture with greater velocity, while the
vessel, from its unfilled condition, enjoys greater latitude of motion
for its own vibrations and those of the enclosed blood. It was pro-
bably these circumstances which betrayed Laennec into the erro-
neous supposition that murmur from compression could only be
produced in the hypochondriacal (De V Auscult. ii. 443 and 766) —
a class of patients who are almost invariably anaemic. I have per-
formed the same experiment of compression, with the same result
of murmur and tremour, on the denuded aorta of asses poisoned
with woorara. See p. 79.) In one instance, I have known compres-
sion exercised on the ascending aorta by the consolidated, tubercular
edge of the left lung, which took the mould of the vessel and created
a murmur whenever the patient Jay on her right side, but not other-
wise— gravitation in the latter case withdrawing the lung from the
vessel. Tumours of any kind, resting upon and compressing con-
siderable arterial trunks, may occasion murmur in the same way.
Of this, tumours resting on the abdominal aorta, receiving its pul-
sation and simulating aneurism, present the most familiar instances.
(See Aneurism of the Abdominal Aorta, Fallacies.) Bouillaud
cites a case of a tumour of the left ovary causing murmur in the
iliac arteries ; and a second, in which a mixed uterine and ovarian
tumour, occasioning murmur in the same vessels, was mistaken
PATHOLOGICAL PHENOMENA. 127
for the reputed placental murmur of an extra-uterine pregnancy,
and led to a fatal cesarian operation. (Traite, i. p. 210 and 249.)
I shall hereafter show that the pregnant uterus is probably to be
ranked amongst the tumours in which the attendant murmur is a
result of compression. (See Auscultation applied to Pregnancy.)
Such is the explanation of inorganic arterial murmurs when
occurring under the circumstances of compression. It will be
shown hereafter that compression and other circumstances occasion
a continuous murmur in the veins, and that when arterial and
venous murmurs coexist in the same spot, the result is a continu-
ous murmur with arterial augmentations. (See Venous Murmurs.)
b. Another class in whom the bellows-murmur prevails, consists
of those who are under the influence of excessive loss of blood,
whether by the lancet or by hemorrhage in any form. Here, the
circumstances are precisely the same as in the dogs above described,
and need no further explanation. The jerk and throb of the pulse,
even when small and weak, is well known to all who have wit-
nessed a case of uterine hemorrhage. In cases of active hemor-
rhage, as hemoptysis and even epistaxis, I have known the throb
to supervene sooner than could be accounted for by the quantity of
blood lost. In these cases it appears to be attributable either to the
irritable temperament of the individual, or to the fright which sel-
dom fails to be occasioned by the unexpected appearance of blood.
c. By far the largest class of individuals in whom the bellows-
murmur is apt to occur, consists of young people, especially females,
of delicate, irritable temperament, subject to hysterical and hypo-
chondriacal affections, to nervous palpitation, and in many cases
to hemorrhages. From careful observation during the last ten
years, and from examining the blood of such patients when oppor-
tunity offered, I feel assured that the whole, or nearly so, whether
male or female, are affected with more or less anaemia, that is, a
deficiency in the quantity of the blood, or in the proportion of its
fibrine and red globules, or in both, — constituting in females the
state inappropriately denominated chlorosis. This state is not in-
compatible with a full, but flabby habit of body, and in such sub-
jects especially I have seen the hemorrhagic tendency prevail to an
extraordinary degree, the flux occurring successively from all the
mucous membranes. The seat of the murmur, when cardiac, is
in the aortic orifice and with the first sound, (for the diagnosis, see
Physical Signs of Valvular Disease,) and, when arterial, in the
carotid, subclavian, brachial, crural and abdominal aorta more
especially, though any other large trunks may yield it. The mur-
mur is not constant, but occasional, coming on whenever the cir-
culation is excited, and, for exciting it, the most trivial causes, as
Laennec has observed, are sufficient. I have seen a single cough,
or a full inspiration, or a little flatulence, produce the effect for a
few beats only; while the act of turning in bed, of rising suddenly,
of being startled by any noise, has occasioned it fofseveral minutes.
An emotion of grief or pleasure will sometimes produce a more
128 HOPE ON DISEASES OF THE HEART.
considerable and permanent effect. I have often been assured by
patients that the momentary flash of an idea across the mind, has
sufficed instantly to excite a violent fit of palpitation, and that this
has recurred several times a day, whenever the same idea has pre-
sented itself. The high nervous irritability of the anaemic dogs
(see p. 123) was precisely parallel. That, under so irritable a state
of the nervous system, the heart should contract with spasmodic
abruptness, might be anticipated; and what theory points out, ex-
perience proves ; for the jerking pulse and beat of the heart of a
chlorotic patient in a state of nervous agitation, are too well known
to require further comment. Sometimes, when the nervous ex-
citement is excessive, a violent throbbing is perceptible, as in the
dogs, over the whole body, and the bellows-murmur and thrill are
dislinct in every considerable arterial trunk. (Laennec, ii. 442.)
When such is the case, the anxiety and distress of the patient are
extreme, and his situation is not exempt from danger, though, as
Laennec truly observes, death is rare when the symptoms are in-
dependent of organic disease of the heart.
It may here be remarked that the jerking pulse of anaemia differs
from the inflammatory pulse in neither being full, strong nor hard;
while the inflammatory pulse has neither the jerk, thrill nor bel-
lows-murmur of the anaemic pulse. When the latter is modified by
inflammation, it acquires a little strength which converts it into
what is denominated the sharp pulse — the inflammatory pulse of
feeble subjects. These distinctions, which to the inexperienced
may appear refined in description, are perfectly familiar to practical
men ; and it is of great importance to the young practitioner that
he make himself intimately acquainted with them, as such know-
ledge will not only facilitate his diagnosis, but prevent the unne-
cessary and often, in anaemic nervous cases, pernicious abstraction
of blood for imaginary fever or inflammation.
d. In arterial variz, a variety of aneurism by anastomosis gra-
phically described by M. G. Brechet, (Memoires de 1'Acad. Royal
de Med. torn. iii. p. 136-174, 1833,) bellows-murmur and thrill
exist in a high degree. The tumour in Brechet's case was soft
and spongy to the feel ; it swelled with each systole of the heart,
the cells being dilated, the skin rendered tense and the volume in-
creased ; the skin, moreover, was so thin as to show a net-work of
cells, to which the blood imparted a dark-red colour every time it
was injected by the ventricular contractions. Pressure being made
on the common carotid, the whole tumour became pale and small,
and, on withdrawing the pressure, it rose again, with bruissement,
in from eight to sixteen pulsations. The tumour was found to
consist of arteries dilated, tortuous and forming a web; and the
capillary vessels, venous as well as arterial, were found greatly
dilated : the coats of the arteries were thin, soft" and flaccid. Now,
friction and vibration must in such cases necessarily exist in a
pre-eminent degree ; for the current is broken by an infinity of an-
fractuosities, and the softness of the tumour gives the same laxity
PATHOLOGICAL PHENOMENA. 129
to the arterial walls as they derive in aneemia from the unfilled
state of the vessels. I entertain no doubt, however, that the mur-
mur and thrill would be increased and perhaps converted into a
continuous murmur by anaemia; such tumours, therefore, form no
exceptions to the general rule, that murmur and thrill are referable
to increased friction from modified motion of the blood.
Musical Murmurs have been described by Laennec, and still
more elaborately by Bouillaud, as occurring in the arteries; nor
has their doctrine, to my knowledge, been hitherto controverted. I
feel assured, however, that this phenomenon, no less than the con-
tinuous murmur, is seated not in the arteries, but in the veins.
For, first, the musical murmur is always continuous; whereas, the
arterial bellows-murmur is always intermittent, accompanying the
ventricular systole and ceasing during the diastole ; — a fact of which
the authors alluded to were not aware, in consequence of their
being strangers to the existence of the venous murmur, whence they
did not distinguish it from the arterial. Secondly, I have never
met with the musical murmur except in cases where the continuous
venous murmur existed. The consideration of the musical mur-
mur, therefore, falls under the next section, where the direct proofs
will be given that it is seated in the veins.
SECTION V. — Venous or Continuous Murmur, Hum and Musical Notes.
Laennec was the first that noticed the continuous murmur,
though he mistook its cause. " In some rare cases," says he, " the
bellows-murmur changes, in the carotid especially and even in the
heart, into a continuous murmur analogous to that of the sea, or
that which we hear on bringing a large univalve sea-shell near the
ear. The saccade or shock of the arterial diastole is then no longer
distinguishable, or only very feebly. Sometimes this continuous
murmur exists in one of the carotids or subclavians, while the cor-
responding artery yields the ordinary bellows-murmur, that is to
say, rythmic and isochronous with the arterial diastole. Most
commonly, bellows-murmur (here Laennec means arterial and car-
diac), is exactly circumscribed by the calibre of the artery or by the
capacity of a ventricle. In other cases, on the contrary, (here he
unconsciously describes venous murmur), it is diffuse, and seems
to take place in a space far more extensive (vaste) than the artery
or the heart, of which we no longer perceive either the impulse or
formP (De l'Auscult. ii. 422.) This continuous murmur, Laennec
ascribes, as usual, to nervous spasm of the heart and arteries. He
makes a distinction (which I shall hereafter show to be incorrect)
between it and the continuous rumble of bruit musculaire acci-
dentally excited in a muscle contiguous to the artery under exami-
nation ; yet he adds, as if from some misgivings of his first expla-
nation, " I have sometimes suspected that the continuous murmur
might depend on spasmodic contraction of the sterno-mastoid and
9— d 9 hope
130 HOPE ON DISEASES OP THE HEART.
platysma myoides. I have sometimes, but not always, made it
cease by relaxing these muscles? (Ibid. p. 447.)
M.'Bouillaud, following Laennec, refers the continuous murmur
to the arteries, and connects it with the constitutional cause which
I had previously pointed out, namely, the anaemic state ; but he
confesses that his arterial theory is totally insufficient to account for
all the circumstances attending the production of the murmur.
Upwards of ten years ago I had come to the conclusion that the
continuous murmur was unconnected with the heart and arteries ;
since its diffuseness, and in some cases its singular loudness, were
incompatible with such an idea : I was equally incredulous of its
being an ordinary bruit musculaire ; since its loudness sometimes
incomparably exceeded the most intense muscular sound, and I had
frequently found it excited by mere pressure, which will not give
rise to muscular sound. In this uncertainty as to its cause, I con-
tinued to collect cases and make observations on the continuous
murmur, but had not leisure to concentrate particular attention on
the subject.
Dr. Ward of Birmingham, in March 1837, solved the enigma.
He ascribed the murmur to the current of blood in the veins (Med.
Gaz. vol. xx. p. 7.), and made ingenious attempts to unravel the
perplexities of M. Bouillaud. Since that time, I have made ob-
servations on a vast number of cases, and have found Dr. Ward's
solution correct in the main, but defective in many of the particu-
lars— especially in his explanations of several of the phenomena
described by M. Bouillaud, which are themselves incorrect. As my
limits do not permit me to analyse the able researches of these
gentlemen, I shall describe the venous or continuous murmur such
as I have found it, and shall explain the concomitant circumstances
as I proceed.
The venous murmur is on a much lower key than the arterial
bellows-murmur; for, while the latter is often as high as the note
produced by whispering the letter r and seldom lower than an, the
venous murmur is usually as low as who. This sound, indeed,
offers the most complete and ready imitation of the phenomenon
with which I am acquainted. The hollow sound of a large inces-
sant forge-bellows also imitates it very closely. When there is no
considerable arterial throbbing, the venous murmur maintains an
even tenour, "the saccade or shock of the arterial diastole, to use
Laennec's words, being no longer distinguishable, or only very
feebly." But when the arterial throb is considerable, the murmur
experiences augmentations corresponding with each arterial diastole
or pulse, precisely as when the handle of the forge-bellows is de-
pressed, or when we force the breath while whispering a continuous
who. These augmentations are nothing more than the superaddi-
tion of the arterial whiff to the venous murmur. I have constantly
been able to distinguish the former through the latter by its higher
key, and also by its being closely restricted to the tract of the
artery, whereas the venous murmur sounds wide and diffuse. The
PATHOLOGICAL PHENOMENA. 131
frequent coexistence of this arterial murmur has led M. Bouillaud
into the error of imagining that augmentations are one of the in-
separable and essential characters of the continuous murmur, which
is far from being the case. In some instances, I have observed that
the arterial whiff seems momentarily to check the venous murmur,
and I think it probable that, by compressing the vein enclosed
within the same sheath, it actually does so ; for the art of swallow-
ing certainly produces this effect, in consequence of the internal
jugular vein being compressed by the elevated os hyoides. The
result is, that a sound is produced conveying to the mind the im-
pression of a current rushing forward, and then back again — which
is, indeed, an expression of the fact, except that the currents are in
different vessels. I suspect that it is this phenomenon which has
led M. Bouillaud to denominate the continrous murmur "bruit de
soufllet continu ou a double courant."
The venous murmur, whether simple, humming or whistling,
(for I shall presently show that it presents these two latter charac-
ters), increases and diminishes, or suddenly ceases and as suddenly
returns, from causes which appeared capricious and inexplicable to
M. Bouillaud, in consequence of his erroneously ascribing the mur-
murs to the arteries, but which are perfectly simple and explicable
on the correct view, and constitute, indeed, so many proofs that the
phenomena arc seated in the veins.
a. When the vein under examination is very superficial — merely
subcutaneous, as the external jugular, very light pressure with the
stethoscope will increase the murmur by partially contracting the
calibre of the vessel ; but if the vein be obliterated by laying the
point of the finger lightly upon it above the stethoscope, or by
depressing the upper edge of the stethoscope, the murmur instantly
ceases. It is seldom, and only in the most marked cases, that
murmur can be detected in the external jugular veins. That of
the internal jugular may easily be mistaken for it by novices.
b. Strong pressure with the stethoscope, sufficient to obliterate a
subcutaneous vein, as the external jugular, instead of suspending
the murmur, swells it gradually to a surprising degree of intensity
and diffuseness, like blowing the word who with great force, mixed
up with which sound I have frequently heard humming, cooing
and whistling notes, appearing to proceed from several veins at
once, which I shall hereafter show to be the case.
It was this extremely loud murmur which first led me to suspect
that the continuous murmur of Laennec was neither seated in the
arteries, nor occasioned by ordinary bruit musculaire. The loud
murmur in question, though noticed by Bouillaud, *(ii. p. 214), has
not hitherto been explained. I have found it to depend simply on
the circumstance of the compressed veins being more deeply or
remotely seated, whence, though the depression of the stethoscope
is forcible, the pressure exercised on the veins is only moderate —
such as merely to contract, without obliterating their calibres. It
is not always necessary that the stethoscope should be placed
9*
132 HOPE ON DISEASES OF THE HEART.
directly over the vein, the same effect being produced by its dis-
placing parts, and thus creating pressure laterally. These facts
are easily put to the test on the internal jugular vein. This vessel
runs, as depicted in Fig. 1, in front of the carotid artery, along the
anterior margin of the sterno-mastoid muscle from the angle of the
jaw to below the middle of the neck, and is separated from the sur-
face merely by the integuments and platysma myoides. If the
stethoscope be placed on the posterior side of the sterno-mastoid
muscle while the face is averted but the neck kept perfectly erect
and the chin well raised, firm pressure gradually develops the
loudest continuous murmur that it is possible to create in the indi-
vidual under operation, and it is " caeteris paribus" louder in pro-
portion as the subject is more anaemic and excitable. If the point
of a finger be now nicely dropped on the internal jugular vein in
any part of its course, so as to obliterate the vessel, yet without
obliterating the carotid, the loud murmur instantly ceases, and
nothing is heard but a dull, obscure rumbling, seated in smaller
veins. This may sometimes be further diminished by obliterating
the external jugular, but it cannot always be completely annihilated,
because it occupies deep-seated veins beyond the reach of sufficient
compression. It is occasionally mixed up with puny humming
and whistling notes. If the finger be now raised again from the
internal jugular, the torrent rushes down and restores the original
loud murmur almost as promptly as when the finger is raised from
the hole of a wind instrument. By alternately raising and depress-
ing the finger, the most sceptical may soon convince himself that
the seat of the murmur is really in the vein. One or two precau-
tions are requisite. If the neck be displaced from the perpendicular,
the sterno-mastoid muscle is apt to be put so much on the stretch
as to obliterate the internal jugular and suspend the murmur.
Again, if the stethoscope, placed behind the sterno-mastoid, press
that muscle too much forward, it will obliterate the internal jugu-
lar. Again, if the skin be stretched across the neck, under the
stethoscope, the tension will increase the murmur in most; but in
a few, whose internal jugular is very superficial, it will obliterate
the vessel and suspend the murmur.
I have met with the remarkably loud murmur in question, not
only in the internal jugular veins, but also on the abdomen, —
principally, I think, over the right side of the umbilical and epi-
gastric regions, where lie, in addition to the internal mammary
veins, the great converging branches of the vena portae and the
renal veins. Very heavy pressure with the stethoscope is requisite
to excite the murmur on the abdomen. 1 have generally met with
it accidentally, when exploring pregnancy or supposed aneurisms
of the abdominal aorta, and the instances of rts occurrence to me
may have amounted to fifteen or twenty. I have likewise met with
a less degree of the continuous murmur in the iliac and hypogastric
regions, its seat probably being, the external iliac and the epigastric
veins; and I have ascertained by researches directed specifically to
PATHOLOGICAL PHENOMENA. 133
the subject, that both arterial and venous murmurs may be excited
by pressure on the several vessels enumerated, in the majority of
anaemic and excitable subjects with a quick pulse, whether they
are emaciated or otherwise. The further consideration of abdomi-
nal murmurs is reserved for the Chapter on Auscultation applied
to Pregnancy.
c. It was stated under the preceding head, that the loud murmur
there considered, swelled gradually : that is, when the stethoscope
is first applied, it is inaudible or slight; but after a few seconds it
begins to swell, and this progressively increases till, in the course
of from ten to twenty or thirty seconds, it attains its maximum of
intensity. I was some time before I could unravel the cause of
this gradual swell, but at length discovered that it depended on
the simple circumstance of congestion of the veins above the part
compressed, by which congestion, or, in other words, increased vis
a (ergo, the current through the compressed portion of vein is ren-
dered stronger and more rapid : therefore, as the congestion takes
place gradually, the swell of the murmur is gradual in the same
proportion. I was led to this discovery by observing that the
murmur of the external jugular did not attain its maximum of
loudness and become musical in a certain case, till the portion
above the stethoscope became exceedingly tumid.
I have further observed that the loud murmur of the internal
jugulars becomes louder during inspiration. — especially about its
end, and weaker during expiration. I ascribe it to expansion of
the lun^s opening a freer channel to the blood on the ri^ht side of
ore ~
the heart and thus depleting the jugular veins below the part
compressed. — circumstances which, by creating a tendency to a
vacuum, would accelerate the current through the compressed
portion, while the un rilled vein below would be in a state favour-
able to the ripple of its current and the vibration of its walls. Dur-
ing expiration, the circumstances are reversed, and the opposite
effect is therefore the result. I have noticed that when an anaemic
person becomes faint from standing long under examination, the
murmur, previously loud and constant, becomes extinct except
during the inspirations. This evidently proceeds from a deficient
afflux of blood to the head, whence there is not a sonorous current
down the veins, except when it is favoured by the suction of in-
spiration. For the latter reason, the murmur exists during inspira-
tion only, in those who barely exhibit the phenomenon at all, — for
instance, the convalescents from anaemia.
d. In the subdivision b. it was stated that, in order to produce
the murmur of the internal jugular in perfection, it was necessary
to avert the face while the neck was kept perpendicular and the
chin well raised. The mode in which this position acts is. in my
opinion, by placing the vessel in a state of moderate tension, which
is favourable to the vibration of its walls, and also increases the
sonorous effect of pressure accidentally exercised on it at any par-
ticular point, as, for instance, by the sterno-mastoid muscle where
134 HOPE ON DISEASES OF THE HEART.
it crosses in front of the vein. Accordingly, when the head is
restored to its natural position, or is depressed, the vein is relaxed
and the murmur ceases or greatly diminishes. A beautiful illustra-
tion of the effect of tension of a vein in producing murmur, is pre-
sented by the following case of one of my present patients at St.
George;s Hospital, January 18, 1839. Phebe James, set. 13, has
consolidation, contraction, inexpansibility and universal dulness on
percussion of the right lung, connected with dilatation of the
bronchi, yielding singularly loud pectoriloquy and gargouillement
over the upper and middle lobes. No phthisical emaciation or
perspirations, though copious expectoration has existed constantly
for three years. The left lung is greatly hypertrophous and uni-
versally presents puerile respiration. By these circumstances the
heart is displaced so completely to the right side that the ascending
aorta can be felt to beat between the second and third right ribs,
about one and a half or two inches from the sternum. In this spot,
the two sounds of the heart, especially the second, are loud and
perfectly exempt from murmur; but, on listening at the edge of
the sternum, a continuous murmur ivith, augmentations corre-
sponding' to the pulse, becomes audible and may be traced icith
increasing loudness along the tract of the vena innominata across
the sternum to the opposite side. Here, I can only suppose that
the stretched state of the vein renders it more susceptible of vibra-
tion and of the sonorous effect of accidental indentation from parts
which it crosses. There was venous murmur in the jugulars also,
the patient being anaemic. (The notes of the case were taken for
me by Messrs. Pollock and Mayor, students of St. George's.)
e. M. Bouillaud states, and Dr. Ward acquiesces, that the con-
tinuous murmur in the jugular veins ceases or diminishes when the
larynx is pushed to the opposite side; whence M. Bouillaud
imagines that the larynx and trachaea constitute a sort of sounding
board to the carotid arteries, in which he supposes the murmur to
be generated. The whole is a mistake. When the murmur ceases,
it is most frequently in consequence of the thumb being inad-
vertently placed upon and obliterating the internal jugular; but it
is sometimes in consequence of the tension of the skin being so
great as to obliterate the internal jugular either by compressing it
against the anterior margin of the sterno-mastoid or by depressing
this muscle upon the vein at the point where they cross. When
these several circumstances are avoided, and the larynx is pushed
aside with moderate force, the murmur, so far from being dimi-
nished, is increased ; for I have found that moderate transverse ten-
sion of the skin generally produces this effect — perhaps by giving
steadiness to all the parts beneath, which is favourable to vibration
and to the production of local indentations on, veins by contiguous
muscles or by external agents.
As the respiratory murmur simulates the venous murmur,
learners should request the patient to hold his breath.
f M. Donne and M. Bouillaud, who quotes him, state that any
PATHOLOGICAL PHENOMENA. 135
considerable corporeal efforts immediately suspend the continuous
murmur. I have not found this to be the case, and I imagine that
those gentlemen have been deceived by inadvertently allowing the
head to fall into some of the positions above described as unfavour-
able to the production of the murmur.
g. Laennec thought the continuous murmur to be louder and
more frequent on the right of the neck than on the left, while M.
Bouillaud has come to the opposite conclusion. I have scarcely
ever found it on one side without being able to discover it on the
other, but I think it is generally louder on the right side, — pro-
bably in consequence of the course of the vein to the heart being
straighter, and therefore more favourable to hydrostatic pressure.
h. After the explanations above offered, it is evident that there is
nothing which does, or can imitate the venous murmur but bruit
musculaire. That, however, it is not muscular sound, is to me
certain for the following reasons: 1. Bruit musculaire can be
created by muscular action in healthy subjects; but the murmur
in question cannot be excited, or only very slightly, except in
anaemic or naturally thin-blooded subjects. 2. I have placed the
end of one finger on the external jugular vein, and the end of
another on the internal, above the stethoscope: by depressing both
I could wholly and instantly suspend the murmur, and by raising
either. I could reproduce it at pleasure in either vein. Now, a
murmur from bruit musculaire would not be suspended by de-
pressing the point of a finger on a {e\v fibres of a muscle. To suc-
ceed with this experiment, the od'^o of the stethoscope must only
lightly touch the side of the external jugular, the murmur of which
can with difficulty be excited, and only in marked cases.
It is quite manifest to me that Laennec actually did mistake the
venous murmur for bruit musculaire. No one will, I think, doubt
this who compares the following passage from that author with all
that precedes. "An inexperienced observer might believe in the
existence of a bruit de soufflet (of an artery) without its being real,
when bruit musculaire is accidentally developed in a muscle near
the artery explored. This happens especially in the carotid, in
some persons labouring under more or less considerable nervous
{and ancsmic ?) agitation. If, when the patient is seated, we make
him incline his head to the left side, so that it be sustained solely
by the right sterno-mastoid muscle, this muscle then takes on the
mode of contraction which yields the bruit de rotation (rumbling
of distant wheels — really, the venous murmur.) Further, the
carotid, swelling at each diastole, impresses a slight shock on the
muscle, the rumble of which then appears intermittent like the
arterial whiff, and from that circumstance strongly resembles the
bellows-murmur (in arteries); but with a little attention it may be
perceived that the rumble is remittent rather than intermittent.
(Here Laennec evidently describes the continuous venous murmur
with its augmentations from the arterial whiff.) We should not,
however, trust the position of the patient; for, on causing him to
136 HOPE ON DISEASES OF THE HEART.
make a very slight movement of the head towards the side under
examination, or on supporting the head, were it only with one
finger, we instantly suspend the bruit musculaire. I have some-
times suspected that the continuous murmur, of which I have
spoken above, might also depend on a spasmodic contraction of the
sterno-mastoid and platysond myoides. I have sometimes, but not
always, made it cease on 'putting these muscles off the stretch."
(De l'Auscult. ii. p. 447.)
Dr. C. Williams has fallen into the same mistake as Laennec ;
for, as shown above at p. 81, he has quoted the very same cir-
cumstances as exemplifying what he considers to be the type of
bruit musculaire. Thus, in so strenuously ascribing the first sound
of the heart to bruit musculaire for the last ten years, he has been
ascribing it to a non-entity; for I am strongly inclined to believe
that, not only in the neck but universally, bruit musculaire will
hereafter be found to be nothing more than a venous murmur ex-
cited by the muscular contraction. This idea does not originate
with myself. I heard it suggested many years ago, but cannot
recollect by whom.
I have never been able to feel a thrill in the external or internal
jugular or any other vein, but I have felt it over the arteries of a
part yielding venous murmur: it may be a question, therefore,
whether the current in veins is strong enough to produce a thrill,
and whether, when it exists over veins, it is not referable to the
concomitant arteries. Laennec seems to have observed a diffuse
tremour. " Sometimes, on the contrary, and particularly in the
carotid, the tremour is much more extensive than the diameter of
the artery, and appears to be more superficial. The tremour of the
carotid is sometimes perceptible over a space two inches wide on the
sides of the neck, and then it is more perceptible in proportion as
the extremities of the fingers are lightly pressed on it. This tre-
mour then appears to be continuous, and the arterial shock is not at
all felt."
Musical Venous Murmurs. It has been stated (p. 129) that
musical notes in the blood-vessels are not seated in the arteries, as
Laennec, Bouillaud, &c. imagine, but in the veins. The proofs of
this are now to be offered.
By the adroit management of pressure with the stethoscope over
or near large veins, the venous murmur may often be raised, by a
gradual swell, into a more or less musical hum, such as is yielded
by a child's humming top. I propose to denominate this the
Venous Hum; for without being unnecessarily squeamish, I
think that this is not only a rather more euphonous epithet, but
more intelligible than noise of the devil, by which term, derived
from a plaything known to few, M. Bouillaud has designated the
hum in question.
Sometimes, again, either with or without hum and with much
or little murmur, we hear a more perfect, continuous musical note,
like a delicate whistle produced by the lips— or by the wind tra-
PATHOLOGICAL PHENOMENA. 137
versing a keyhole or crevice, or, in some instances, like the singing
of a kettle, or the song of a musquito fly.
In proof that these musical notes are generated in the veins, and
not in the arteries, the following, out of many other cases of the
same kind, may be adduced. On a large bronchocele, in an anaemic
boy of ast. 15. a musical note like the slightest whistle, and a con-
tinuous dull, rumbling murmur, were both suspended whenever I
pressed my ringer transversely on the neck, above the tumour, so
as, without compressing the carotid artery, to obliterate the super-
ficial veins descending over the surface of the tumour. A still
more conclusive proof is, that in a patient now before me, I can at
pleasure create a musical note like the song of a fly (running
alternately on a tone and a semitone above), in the external jugular
vein, by delicate and well-managed pressure on that vessel with the
stethoscope ; but the note stops the instant that I place the point of
my finger on the vein above. Further, by heavier pressure with
the stethoscope, I can at pleasure develope an exceedingly loud
venous murmur in the internal jugular, together with a beautiful
musical note like the singing of a kettle, which runs continuously
on two notes, the one a perfect major third above the other. The
transition is marked by the arterial pulsations, and the two notes
generally alternate at each pulsation ; but sometimes the lower note
persists during three or four consecutive pulsations, being merely
augmented by each. Further, I can create the musical notes, not
only by pressure with the stethoscope but also with my finger.
For on lightening the pressure with the stethoscope, so as to extin-
guish the musical note but leave the ordinary loud venous murmur,
I can reproduce the musical note by pressure with the point of one
finger over the internal jugular vein in front of the sterno-mastoid
muscle, below the jaw, the chin being raised and averted ; and, by
increasing or diminishing the degree of pressure (always without
obliterating the vein) I can raise or depress the note at pleasure,
sometimes a whole tone, sometimes only half. On depressing the
finger with sufficient force to obliterate the vein, without obliterating
the carotid artery, the continuous murmur, together with the mu-
sical notes, instantly cease : which is a conclusive proof that both
are seated in the vein. I have found very few cases in which I
could make this experiment succeed so well.
The internal and external jugular are not the only veins of the
neck in which the musical murmur can be produced. I have found
in several cases that, when I obliterated these vessels and suspended
their venous murmur, puny musical notes and a feeble obscure
rumble could be developed by well-managed pressure with the
stethoscope on the intermediate space. Their seat was probably
in the smaller and deeper-seated veins corresponding with the
branches of the subclavian. The musical note was so weak as to
be drowned by the loud murmur of the internal jugular whenever
the finger was removed from this vessel.
Stretching the skin transversely under the stethoscope, often
138 HOPE ON DISEASES OF THE HEART.
favours the conversion of an ordinary venous murmur into a musi-
cal note, the cause being, an increase in the fineness and rapidity
of the vibrations.
Musical notes are much more difficult to produce when patients
are recovering from anaemia. They appear to me to be most com-
mon in a class of young females of what is called the " phlegmatic
temperament,'' that is, with a lax, flabby muscular system, large
blood-vessels, thin arterial coats, proclivity to hemorrhages, often a
rather full habit, and whose blood, even during health, contains less
than the average of ribrine and red globules.
In all cases, the production of the musical murmur requires
patience and adroitness ; as the auscultator may be foiled again and
again and as if capriciously, by an unhappy position of the stetho-
scope, a deficiency or excess of pressure, or a movement of the head
relaxing the veins or the skin.
Mr. Mayo and Mr. Wheatstone lately did me the favour to
examine three patients and verify most of the preceding facts.
If the above account be now compared with Laennec's descrip-
tion of musical notes existing, as he erroneously imagines, in the
arteries, it will be manifest that we are each alluding to the same
phenomenon, and, therefore, that its seat is in the veins.
"The arterial bellows-murmur," says this acute observer, "fre-
quently passes (especially at times when the patient is more agitated
than usual by any cause whatever) into a whistling analogous to
that of the wind blowing through a keyhole, or to the resonance of
a metallic chord which vibrates long after having been touched.
The resonance of the diapason which issued to tune keyed instru-
ments, may also be perfectly imitated by the whistling noise of
arteries. These sounds, always feeble, are nevertheless very ap-
preciable, and we may easily find the note that they represent in
reference to a given key-note or diapason : further, in some cases,
rare it is true, the sound ascends or descends by intervals of a tone
or half a tone, as if the artery had become a vibrating chord on
which a musician produced successively two or three notes by
advancing or withdrawing his finger." (De l'Auscult. ii. p. 423.)
Laennec describes one case in which the air ascended and descended
on three notes constituting a major third, except that the upper
note was slightly too flat. The " transition from one note to the
other," says he, " was occasioned by each arterial diastole," and the
lowest note or ionie was sometimes sustained for a variable period,
the arterial diastole then occasioning merely an increased intensity
of the sound, which decreased during the systole. This same
variation in intensity occurs, he says, when the musical sound is
confined to a single note. Occasionally, the sound fails during the
systole, and is only heard during the diastole. The music may
from time to time cease suddenly and be replaced by an ordinary
bellows-murmur, and, when the circulation becomes calm, it ceases
altogether. Such is the substance of Laennec's account of musical
murmurs.
PATHOLOGICAL PHENOMENA. 139
Some have experienced a difficulty in conceiving how an ordi-
nary murmur should be converted into a musical note. It has
already been stated, in reference to musical murmurs of the valves
of the heart, that there is but a shade of difference in the mechanism
by which we make the lips produce a blow or a whistle, the latter
depending on the happy and steady adaptation of the size of the
aperture to the strength of the current. A more apposite illustra-
tion may be drawn from the child?s toy called the humming-top — •
a hollow top with a hole in the side, and spun by drawing a string
twisted round the upper end of its axis. When the string is first
drawn, it dances about with a humming murmur; but when it
becomes steady and, in the child's phrase, '-goes to sleep," the hum
is gradually converted into a clear and agreeable musical tone,
which dies away again into a feebler hum as the rotation becomes
too weak to maintain it. Here, a certain proportion between the
velocity of the current of air and the size of the aperture, aided by
the steadiness of the instrument, gives rise to fine vibrations in the
wood calculated to be musical. A step further brings us to wind
instruments. Every expert flute player knows that the purity,
richness and variety of his tone depends, not on the brute strength
with which he blows, but on a happy adaptation of the volume and
strength of the current of air to the size of the embouchure, which
he increases or diminishes at pleasure by withdrawing or advanc-
ing his lips over it : also, that steadiness is indispensable, the
slightest quiver of the lip or movement of the instrument being
fatal to the tone: further, that he can "force"' a "reedy" tone on
the lower notes to a surprising degree of loudness; whereas, one
who has not the art of producing a reedy tone can never produce
even loudness, though he blow with ten times the force : finally,
that an exquisite note, scarcely louder than a whisper, may be
elicited by a current of air so fine and feeble as to be inaudible even
to the player.
Now, why is not a vein in circumstances analogous to those of
a flute ? We are certain that it can produce sonorous vibrations,
for we hear the murmur. Why may not the several circumstances
be so happily adjusted as to render the vibrations musical ? Why
may not the note admit of being " forced" as we actually find it to
be by the arterial diastole? Why, if the relation of circumstances
continues correct, may not the note persist in any degree of delicacy,
during the feebler venous current connected with the arterial sys-
tole and subsequent repose? Why may not the note be suddenly
arrested (as we actually find it to be), when the adjustment of cir-
cumstances is disturbed by accidental extrinsic causes, as an undue
increase or diminution of pressure, a movement of the head, (fee?
And why should not the music permanently cease, when, from
diminution of nervous and arterial excitement, the circulation be-
comes too calm to produce the requisite vibrations? If these con-
siderations be true, the phenomenon is explained so far as it lies
within the province of the physician : it is for the professor of
140 HOPE ON DISEASES OF THE HEART.
acoustics to develope the ultimate laws by which given vibrations
produce musical, rather than murmuring sounds.
The constitutional causes of the venous murmur, hum, and
whistle are exactly the same as those of the arterial bellows-mur-
mur. Laennec had stated this to be "very common in hypochon-
driacs and hysterical women ; also in delicate irritable young people
subject to hemorrhages ;" but it was not understood by him or
others that ancemia was an essential character in these, and all
other cases yielding inorganic murmurs, until this fact was pointed
out in the first edition of the present work in 1831, in connection
with the experiments on dogs by repeated blood-letting (see back
p. 123). Since that period, I have not met with any instance of
the venous murmur in a marked degree, in which anaemia was
absent. I have to-day found it in the highest perfection in eight
out of a hundred of my female hospital patients, and slightly in
five more. The whole were anaemic. Further, I have invariably
found that the murmurs, &c. gradually disappeared in proportion
as the anaemic state was removed by iron, aloetic aperients, animal
food and fresh air. If confirmation of facts so easy to be proved
were wanting, I might cite the more recent researches of M. Bouil-
iaud, who was acquainted with, and quotes my experiments on
dogs (Traite, i. p. 182), who followed up the same train of investi-
gations and arrived at identical conclusions. Thus, he says, "In
all the patients in whom I have hitherto met with the noise of the
devil and its various shades, what is the most remarkable general
and constitutional condition, if it is not a state of real ancemia, or
at least a state of the blood in which the serous portion predomi-
nates over the red particles and fibrine — a state which the reader
will permit me to designate by the term of hydr&mia (watery blood)
to avoid circumlocutions? If this state is, as must be presumed,
one of the principal causes, if not the sole cause, of the noise of the
devil, is it not probable that this noise should exist in individuals
who, in consequence of accidental losses of blood or of copious
blood-lettings and a diet almost wholly aqueous, have fallen into a
temporary, but real state of anaemia or hydraimiaT {Traite, i. p.
22.) This is an almost verbal confirmation of the passage above
alluded to, at p. 75 of the first edit, of this work, and at p. 124 of
the present.
It must be understood that, under the term anaemia, I comprise
all patients, whether male or female, whose countenance exhibits
an exsanguine paleness, whose blood is thin and serous, and who,
in addition, have usually palpitation and shortness of breath on
exertion, weakness and aching of the limbs and back, lassitude,
constipation, anorexia — usually with disgust at animal food, and,
i( females, amenorrhea or menorrhagia — though these are not
essential characters. I have, however, frequently found a slight
degree of the venous-murmur in healthy persons with naturally
thin blood. The term chlorosis, (from xXu^) viridis, green or
greenish yellow,) should be discarded ; as habit has restricted it to
PATHOLOGICAL PHENOMENA. 141
females, and connected it with a doubly false theory ; since chlo-
rosis is not necessarily attended either with a -green and yellow"
colour or with suppressed eatamenia.
The limits of the present work will not admit of the citation of
cases of inorganic murmurs, though upwards of fifty are in my
journals, and I feel sure that I have seen three or four times that
number. Nothing, indeed, but weariness of noticing the same
thing has prevented the number from being much larger ; for the
venous murmur exists more or less in almost every case of anaemia,
and of such cases, my hospital out-patients alone afford upwards of
three hundred per annum.
The knowledge of the venous murmur is a useful accession to
medical science ; for it not only constitutes a criterion of the anaemic
state and of the degree of attenuation of the blood, but facilitates the
diagnosis of organic from inorganic murmurs of the valves, by
affording strong presumptions of the latter.
SECTION VI.— Purring Tremour or Thrill of the Heart and Arteries.
Though all the circumstances of this phenomenon have been
noticed in connection with the various murmurs which it accom-
panies, yet it may be convenient to collect them into a brief synop-
sis. Tremour arises from the vibrations into which the blood and
surrounding solids are thrown during the passage of the fluid
through an obstructed orifice or through imperfectly filled or rough
vessels.
1. In the heart. Tremour is produced by contraction of the
semilunar valves or of their respective orifices; but it is rarely felt,
because the sternum is interposed: if. however, the heart is dis-
placed from beneath the sternum by hydrothorax, empyoerna, (even
circumscribed.) emphysema, encephaloid or other tumours, &c. the
tremour may then become perceptible in the region of the semi-
lunar valves. A tremour of the pulmonary artery, however, whe-
ther resulting from contraction of its orifice or from dilatation or
ossification of the artery itself, may often be rendered perceptible by
no other displacement than that resulting from an inclination to
the left side while the patient lies in the horizontal position; in
consequence of which, the upper part of the vessel is brought by
gravitation between the cartilages of the second and third ribs,
where the tremour can then be felt. In dilatation of the pulmonary
artery the tremour is very distinct at this point, though the patient
be erect. (Cases of Wetherley, L. P., and Bowden.) A regurgita-
ting current through the semilunar valves produces less tremour
than a direct one, because it is weaker. A current, both direct and
regurgitating, out of the aorta through an aneurism into the mouth
of the right ventricle, produced a strong tremour in the case of
Mitchell, whose heart was also displaced.
Regurgitation through the mitral valve I have observed to be
142 HOPE ON DISEASES OF THE HEART.
beyond comparison the most frequent cause of tremour in the
heart, since the current is strong, and the tremour admits of being
felt through the costal interspaces. It is very rare in the tricuspid
valve, because the refluent current is weaker, the valve itself is
seldom diseased, and the situation is more covered by the sternum.
I have never known the direct current through either auricular
valve to produce a tremour, the stream, I presume, being too weak.
A strong tremour is produced in pericarditis by the attrition of
dry lymph, or the agitation of a small quantity of serum between
layers of rough lymph (case of Jones).
I have never known tremour to exist in the heart independent
of organic causes.
2. In the arteries. Considerable contraction of the aortic valves
will occasionally propagate a tremour as far as the carotid and
subclavian arteries during palpitation, or even during a calm state,
provided there is great hypertrophy with dilatation; but it is rarely,
if ever, propagated so far as the radial s, unless the effect is favoured
by an unfilled state of the arteries from anaemia or aortic regurgita-
tion. Roughness or dilatation of the ascending aorta and arch
occasions tremour in the vessel itself and also in the carotids and
subclavians, even during a state of calm : during palpitation, espe-
cially if there be hypertrophy, it may be propagated in a slight
degree as far as the radials.
Aortic regurgitation, by unfilling the arteries (a state highly
favourable to their vibration), may, during palpitation, propagate a
tremour as far as the radials or still more remote arteries.
3. Inorganic tremours. Anaemia, on the same principle of
unfilling the arteries, favoured also by the watery state of the
blood, may, during nervous excitement, give rise to a thrill in any
or all of the more considerable arteries, but especially in the caro-
tids, subclavians, brachials and crurals. I at present attend a
highly anaemic young lady with a pulse of 150, in whom it exists
in a most marked degree in the radial artery. The co-existence of
anaemia and aortic regurgitation augments the effect, and both, or
either favours the operation of the organic causes.
As tremour has the same origin as bellows, musical and other
murmurs, it is always accompanied by them; but, as it requires
a greater degree of vibration for its sensible development, they may
exist without being accompanied by it.
O
AUSCULTATION APPLIED TO PREGNANCY. 143
CHAPTER V.
AUSCULTATION APPLIED TO PREGNANCY.
M. Mayor, of Geneva, was the first who applied auscultation to
the study of pregnancy by discovering, before the year 1818, that
the beats of the foetal heart could be heard, and distinguished from
those of the mother, by applying the ear to the abdomen (Biblio-
theque Universelle, torn. ix. for Nov. 1818: see note by the editor
to M. Percy's report to the Institute on Mediate Auscultation). As
M. Mayor never afterwards published, Laennec infers that he did
not extend his observations beyond the above remarks. In 1822;
M. Kergaradec, apparently unacquainted with M. Mayors dis-
covery, published his memoire on Auscultation applied to the
Study of Pregnancy, and his results have subsequently been more
or less verified, corrected, and extended by innumerable ausculta-
tors, including, especially, M. Laennec in 1826, Dr. Ferguson,1 Dr.
Kennedy,2 M. P. Dubois in 1832,3 and M. Eouillaud in'l835.
The two signs which are considered to indicate a living foetus in
utero, are, 1. The double sound of the foetal heart; 2. A murmur
usually called utero-placental.
1. The double sound of the foetal heart. Writers, including
Laennec (ii. 466), have said so much on the difficulty of hearing
the fcetal beat, that the following preliminary directions, by which
that difficulty may in a great measure be obviated, will not, per-
haps, be unacceptable to the novice.
It is useless to attempt an examination in the erect position and
through the ordinary dress. The stays should invariably be taken
off, as their compression above tightens the walls of the abdomen
below. The patient should be in bed, on her back, with the shoul-
ders raised and the knees drawn up and supported; and she should
be covered by a chemise only, or a single sheet of a soft quality, as
stiff linen creaks under the stethoscope. The abdominal walls are
thus completely relaxed, so as to allow the foetus in utero to be
readily felt, the situation of its back tolerably well ascertained, and
the stethoscope to be pressed down into solid contact with the
uterine tumour. This depression of the instrument should be
exercised solely with the head of the auscultator, and not with his
hand, as the bruit musculaire of the latter greatly obscures the
fcetal sound. The impossibility of exercising similar depression
when the ear alone is employed, constitutes the advantage of
mediate, over immediate auscultation in the exploration of the
abdomen. Profound silence is desirable; the auscultator should
1 Dublin Med. Transac.
2 Dublin Hosp. Reports, vol. v.
s On the application of auscultation to the practice of midwifery, in the
Archives Gen. de Med., torn, xxviii. Paris,
144 HOPE ON DISEASES OF THE HEART.
hold his breath, and he will find his delicacy of hearing increased
by also opening his month. He should carefully avoid a stooping
position and the slightest bend of the neck, both of which circum-
stances impair the hearing by causing congestion of the head.
These two latter reasons constitute almost as strong objections to
short stethoscopes as to the naked ear.
The abdominal sounds from which, or through which the aus-
cultator has to distinguish the foetal beat, are, a. The sounds of the
mother's heart, sometimes audible on the abdomen, which may
easily be discriminated by their synchronism with her pulse and
anachronism with the fcetal beats, b. Intestinal borborigmus. The
listener must wait till it is over. c. Bruit musculaire of the abdo-
minal parietes. The pressure of the stethoscope scarcely excites it
if the parietes be well relaxed by position, d. Loud arterial and
venous murmurs, to be described under the next head. They
occur principally in anaemic subjects. It is sometimes difficult for
a novice, on a first trial, to separate, as it were, and identify the
fcetal tic-tac amongst so many other sounds : once distinguished, it
is so peculiar as never afterwards to be forgotten. We now proceed
to consider the fcetal beat itself.
The beat of the fcetal heart has been heard by Dr. Kennedy as
early as the end of the fourth month. I have repeatedly heard it
at four months and a half, and earlier, provided that the mother's
calculations were correct. Velpeau and Bouillaud say four months
and a half. Laennec therefore placed the date rather too late in
fixing it at the " beginning of the sixth month and sometimes a
little earlier." Dr. Montgomery says he has not been able to hear
the beat before the completion of the fifth month.
The beat exactly resembles that of a young rabbit or kitten, and
is closely represented by the tic-tac of a watch thickly covered by
a pillow. It is feeble during the first half of the fifth month, but by
the end of the month it becomes strong and distinct, when listened
to in the best situation, presently to be described. M. Dubois says
that when the beats are quite distinct, they are very frequently
attended with bellows-murmur, and he ascribes this to the mixture
of the two columns of blood of the pulmonary artery and the aorta.
Bouillaud has heard an approximation to bellows-murmur in a few
cases. I do not happen to have noticed it.
The speed of the fcetal beat, 1 have found to be as high as 160
and sometimes a few beats more, during the fifth month; during
the sixth, it falls to 150; and during the seventh, to 140: at the full
term I have occasionally, though not often, found it as low as 120.
It is liable to sudden accidental accelerations, even during ste-
thoscopic examination, and often without any disturbance in the
circulation of the mother. (Kergaradec.) 1 have frequently noticed
this, and it may be the reason why some have rated the pulse as
high as 165 so late as the seventh month. On the contrary, I have
sometimes known the fcetal beat suddenly become very slow and
languid — mostly during faintness of the mother, but sometimes
AUSCULTATION APPLIED TO PREGNANCY. 145
without assignable cause, for disturbances of the mother's circula-
tion do not always influence that of the fetus.
The spot where the fetal beat is most audible, varies according
to the position of the infant, which, especially during the seventh
and eighth months of pregnancy, is perpetually changing its posture.
The part of the uterus to which the rounded back and shoulders of
the fetus are applied, is that where the sound is most audible;
since, if the stethoscope be well pressed down, not only any inter-
posed intestine, but also the liquor amnii is displaced, and the
back of the infant, the uterus and the abdominal walls form one
solid conductor for the sound. This part will most commonly be
found on one side or other, in a line from the umbilicus to the
anterior inferior spinous process of the ilium, but occasionally it is
more centrical. During the early part of the fifth month, the part
is very low down, because the uterus has not risen high into the
abdomen. Its extent after the fifth month may be considerable —
equal to an expanded hand. The sound diminishes in intensity
on receding in any direction from the focus of the part in question.
On commencing his examination, the practitioner should place his
hand on the relaxed abdomen and feel for the hardest and most
prominent part of the uterine tumour, where, in the great majority
of instances, he will at once find the tic-tac in full perfection. If he
fail, he should try the other side: if he again fail, he should incline
the mother to the sides as he successively examines them, since the
movement may cause the back of the fetus to gravitate to the
dependent side. If he still be disappointed, he should apply a cold
hand to the abdomen, or exercise some manipulations, which may
occasion a favourable change of position by exciting the efforts of
the fetus itself; for, as Laennec remarks, it may probably be some-
times so placed as not to touch the anterior half of the uterus with
any part of its back, and such he imagines to be the case when the
sound is not audible for hours or days together (ii. p. 459). By
attention to the above rules, however, I have seldom failed to dis-
cover it in a few minutes. Once, when showing it to my colleague,
Dr. Robert Lee, the search cost me a quarter of an hour, but the
tic-tac was finally discovered in great perfection.
So constant and so unequivocal is this sign that I have never
found it absent in pregnancy with a living infant, though I may
have examined upwards of a hundred cases. When the infant is
dead, it is of course absent, and practitioners have occasionally
failed to discover it, under special circumstances, even when the
fetus was alive : for instance, in pregnancy complicated with
ascites (Dr. Montgomery, Cycloped. of Med., Signs of Preg. p. 478).
Its absence, therefore, must not hastily be considered conclusive
against the existence of pregnancy. The great advantage of this
mode of exploring pregnancy, consists in its delicacy and certainty.
The most timid rarely object to it, and, after the middle of the
term, if the tic-tac be heard, it not only supersedes all other modes
of examination, but enables us to affirm that the fetus is alive.
9 — e 10 hope
146 HOPE ON DISEASES OF THE HEART.
la Forensic Medicine, the sign, from its certainty, is of course
invaluable.
In case of pregnancy with twins, it has been found possible to
ascertain this circumstance by the existence of two foetal beats, at
different parts, corresponding neither with each other nor with the
maternal pulse. It is also possible, after the delivery of one infant,
to ascertain the presence of a second. For further details respect-
ing the application of auscultation to parturition, the reader is
referred to Kergaradec, Kennedy, and P. Dubois.
2. The murmur usually called utero-placental. Others have
denominated it the uterine murmur : others, again, the placental,
according to their respective opinions as to its origin. M. Ker-
garadec had the honour of its discovery.
This murmur is considered to be audible earlier than the beat of
the fcetal heart. Laennec says, " we ordinarily begin to hear it
towards the fourth month," by which he means the end of the
third : he then adds, " From the time that the fundus of the uterus
has passed the brim of the pelvis, and can be brought into contact
with the abdominal parietes by pressure with the stethoscope, we
hear the murmur very distinctly, and perhaps even louder than at
the end of pregnancy" (ii. p. 461). This rising of the uterus takes
place in the course of the fourth month of gestation. Dr. Mont-
gomery does not believe that the murmur can be heard at an
earlier period than this, and he has not personally been able to
hear it before the completion of the fourth month. Velpeau thinks
that if Laennec and M. de Lens really heard it before the end of
the third month, it is impossible, for that reason alone, to ascribe it
to the utero-placental circulation (Traite des Accouchemens, i.
p. 190-1). Dr. Kennedy states that he has frequently detected it
in the tenth, eleventh, and twelfth weeks. It will presently be seen
that these discrepant statements are reconcilable on the grounds
that there are several distinct sources of the murmur.
It is exactly synchronous with the maternal pulse. In some
cases, it exactly resembles that produced by compressing any con-
siderable artery, being the ordinary arterial whiff (Bouillaud). In
others, and these are the great majority, it has a prolongation run-
ning into the next arterial pulsation : in other terms, it is a con-
tinuous murmur with augmentations of intensity at each arterial
pulsation (Dr. Kennedy). I have also heard it continuous loith
little or no augmentations.
Laennec remarks that, in the later stages, the bellows-murmur
is almost always dull and very diffused, no longer conveying the
impression of being confined to a single artery. All are agreed
that it is sometimes slightly whistling. (Laennec, Kennedy, Forbes,
Bouillaud, &c.)
The iliac regions are the situations in which all concur in think-
ing that the murmur is most frequently found ; yet it is stated that
there is no particular part of the uterine tumour where it may not
exist (Dr. Forbes, Cyclop. Auscult. p. 242). It is most frequently
AUSCULTATION APPLIED TO PREGNANCY. 147
limited, says Laennec, to a space of three or four square inches,
but it may sometimes be heard over an extent exceeding that of an
expanded hand : as a general rule, however, it is more local and
limited than the beat of the foetal heart. According to Laennec,
Kennedy, Forbes and Montgomery, the spot where it exists does
not alter during the course of the same pregnancy, but it may vary
in different pregnancies and in different individuals. The murmur,
according to Laennec, is not constant. " There are days," says he,
" when we can scarcely find it, and we often hear it cease and
recommence under the stethoscope without moving the instrument."
Kennedy also says, " Intermissions will occur in this phenomenon,
upon what cause depending I cannot say."
Respecting the origin and seat of the murmur, I transcribe the
following summary from Dr. Forbes (Cycloped. i. p. 242), as it
represents the commonly received opinion. " There can be no
doubt that the murmur has its seat in the enlarged vessels of the
uterus^ in that portion of it immediately connected with the
placenta. This is proved by the following facts : — 1. The sound
is confined to a fixed space in each individual. 2. This spot is
ascertained, by examination after delivery, to be always that to
which the placenta had been attached. 3. That the sound is not
seated, at least exclusively, in the placenta, is proved by the fact
that the sound is still audible for a short period after the placenta
is detached. 4. It ceases immediately upon the contraction of the
utero-placental arteries, as is proved in cases of death of the foetus
without delivery, and by its instantaneous cessation on the con-
traction of the uterus after delivery. 5. It is in all cases synchro-
nous with the mother's pulse."
[Dr. C. J. B. Williams presents the following views of the cause of the
utero-placental murmur : " When a current of blood enters a new and
enlarged channel, at a considerable angle, and strikes against its sides, it
communicates to them an impulse which they resist, and the series of
impulses and resistances which thus ensue, if forcible and rapid enough,
constitutes sonorous vibrations. The dilated and tortuous state of the arte-
ries of the gravid uterus, (and the unusual direction of the arterial current
into a lateral or varicose aneurism), presents conditions well calculated to
produce sounds in this manner." — P.]
I am disposed to believe, for reasons which will presently be
submitted, that the whole of these conclusions are incorrect, and
that the entire subject has hitherto been imperfectly investigated.
I believe that Kergaradec, Kennedy, P. Dubois, &c. are in error in
restricting the murmur to the uterus, the placenta, or to both ; that
Bouillaud is equally in error in restricting it to the great arteries of
the pelvis; and that all are in error in restricting it to the arteries
to the exclusion of the veins.
I venture to submit for further investigation the following pro-
positions : —
1. That the murmur is arterial when it is a whiff.
2. That it is venous when continuous without augmentations
synchronous with the pulse.
10*
148 HOPE ON DISEASES OF THE HEART.
3. That it is arterial and venous conjoined when it is continuous
with augmentations.
4. That its seat is sometimes in the vessels of the abdominal
parietes, as the epigastric, circumflexed ilii, internal mammary, and
their branches and concomitant veins ; sometimes in the great arte-
ries and veins within the cavity of the abdomen, as the common
and external iliacs, the renal, the three branches of the coeliac, the
colica dextra, media, sinistra and ileo-colica, and the portal veins ;
sometimes, possibly, in the uterine walls, and sometimes, possibly,
in the vessels of various tumours.
5. That the murmur is generally created by pressure, whether
that of the uterine or other tumour or of the stethoscope ; and that
it does not exist independent of pressure except, possibly, in ansemic
cases.
6. That the stretched condition of the arteries, and especially the
veins of the abdomen, is favourable to the operation of pressure in
producing the murmur.
These propositions cannot be adequately comprehended except
by one who is thoroughly imbued, both theoretically and prac-
tically, with the doctrines of venous murmur developed in a pre-
vious section, (p. 130.) Referring the reader to that section, I
shall first show the analogy between abdominal murmurs and
those observed in the neck, both arterial and venous, and shall
afterwards point out the unsubstantial nature of the arguments
which would restrict the murmur in question to the uterus and
placenta.
The description of the reputed utero-placental murmur which
I have offered above, (p. 146), is designedly drawn from the
ablest writers on the subject, for the purpose of showing that even
their own account is identical with that which applies to ordinary
anaemic murmurs in the neck. The murmur is sometimes a mere
arterial whiff': so it is in the carotids. Sometimes it is continuous
with augmentations : so it is in the carotids and internal jugulars,
&c. Sometimes it is continuous with little or no augmentations :
so it is in the jugulars. Sometimes it is whistling : so it is in the
jugulars. Sometimes it ceases without assignable cause : so it does
in the jugulars to those who do not understand its nature and the
mode of exciting and suspending it. It is most marked in anaemic
subjects : so it is in the neck.
A few instances of the several varieties of murmur, as occurring
in the abdomen, will now be offered, for the purpose of substantia-
ting the above statements.
1. Respecting the arterial whiff.
Case 1. I lately attended a gentleman, in consultation with
Drs. Abercrombie, Monro and Chisholm, in whom an aneurism of
the abdominal aorta presented a whiff synchronous with the pulse,
which was supposed to proceed from the aneurism itself, but which
I believed to be superficial from its high key (the whispered r
AUSCULTATION APPLIED TO PREGNANCY. 149
sound), from its being restricted to a line crossing down the sum-
mit of the tumour, and from its ceasing whenever the stethoscope
was pressed firmly down, so as to obliterate the artery. It was as-
certained, after death, to have proceeded from the superior mesen-
teric artery, which crossed the top of the tumour.
This case is introduced for the purpose of evincing that an
artery, even though not of very considerable magnitude, may occa-
sion a high-keyed, near-sounding whiff through the thickness of
the abdominal walls. A fortiori, an artery seated within the sub-
stance of the walls, would, cceteris paribus, do the same. The
case also shows that a tumour beneath an artery, partly by affording
counter pressure, and partly, perhaps, by placing the vessel on the
stretch, is favourable to the production of a murmur.
The next cases are instances of the arterial whiff in the large
arteries within the abdomen, exclusive of the aorta ; for I deem it
superfluous to adduce instances of the whiff in this vessel, as the
phenomenon is of daily occurrence in anaemic subjects examined in
the horizontal position.
Case 2. An emaciated, anaemic, phthisical man at St. George's
Hospital, November 29, 1838. P. 90, weak. The beat of a deep-
seated artery could be felt on each side of the umbilical region,
crossing from the aorta ; (the renal arteries or the colica dextra and
sinistra?) and on pressing the stethoscope down upon them, a slight
whiff synchronous with the pulse was immediately heard, but
without continuous murmur. The same was heard along the
common and external iliacs on each side.
Case 3. Another man, examined at the same time, with similar
symptoms, presented the same phenomena.
The next case shows that an artery nearer the anterior walls of
the abdomen yields a much louder and nearer sounding whiff, and
that a degree of venous murmur is produced in the accompanying
vein.
Case 4. James Franklin, in St. George's Hospital, November
29, 183S, had pulsation along the whole aorta, but much stronger
and more superficial in the epigastrium than elsewhere. Aneurism
of the cceliac artery had been suspected. An arterial whiff' was
audible all up the aorta ; but, at the upper and left edge of the
epigastrium, there was an exceedingly loud, superficial and pro-
longed, though not quite continuous murmur. It appeared to run
in the line of the splenic artery and vein. I infer that the murmur
was partly venous, because an artery alone never yields a prolonged
murmur. A tumour, whether aneurismal or otherwise, subjacent
to the splenic vessels and thus stretching and compressing them,
would account for this murmur.
The cases hitherto adduced have illustrated the arterial whiff
more especially. . We now proceed to —
2. Continuous murmur with augmentations.
Case 5. A female at St. George's Hospital, November 29, 1838,
oet. 25, single, of full habit, but extremely pallid and ancemic ; P.
150 HOPE ON DISEASES OF THE HEART.
100; abdomen tumid from flatulence. Heard continuous murmur
with augmentations corresponding to the pulse, on each side of the
umbilical region, far from the aorta. The continuous murmur
sometimes ceased and left the arterial whiff alone. This occa-
sionally happened for a few moments at a time, though the stetho-
scope was not moved from the ear, and the cessation was always
connected with an audible movement of flatus under the end of the
instrument. The murmur only existed in a limited tract.
This case satisfactorily proves that the continuous murmur' with
augmentations is compounded, in the abdomen as well as in the
neck, of the arterial whiff superadded to the continuous venous
murmur. It likewise shows that here, as in the neck, the venous
murmur may be suspended by slighter causes than suffice to stop
the arterial whiff.
Case 6. A girl, set. 19, in St. George's Hospital, February 6,
1839 ; very pallid and anaemic, P. 110, with loud venous murmur
on the neck. Placed her on her left side, and examined the right.
About a hand's breadth in front of the anterior, superior spinous
process of the ilium and two fingers' breadth above it, a murmur
was heard under the following circumstances. On firmly pressing
down the stethoscope nothing was heard ; but, after five or ten
seconds, on easing the pressure, a sudden, loud venous rush was
heard, exactly as when the finger is raised from the internal jugular
vein. The rush ceased after four or five seconds, as if the gorged
vein had unloaded itself. It was reproduced ten or twelve times
by the same process, but it was always weaker, and sometimes
failed, during inspiration, as if this act displaced the vessel from
beneath the stethoscope. I apprehend that the rush was occa-
sioned by congestion of the vein resulting from its previous obli-
teration by pressure; for I have shown this to be the explanation
of the same phenomenon in the neck. (p. 133.) I now eased the
pressure in a less degree than before, and thus converted the rush
into a continuous murmur with slight arterial augmentations, and
with an intermixture of delicate musical notes of humming and
whistling. The sounds continued, as before, to diminish during
inspiration. On moving the stethoscope from a particular spot, the
murmur was lost and not easily found again.
This case not only exemplifies the venous murmur dissociated,
as it were, from the arterial whiff, but shows that the murmur may
be musical.
I feel a difficulty in positively determining what vessels were
the seats of the murmur in the two preceding cases. The internal
epigastric is too centrical. The external epigastric and the
branches of the circumflexa ilii are probably too small. The renal
are too deeply seated and are higher up; and I have great dif-
ficulty in fixing upon the common or external iliacs, because I
shall presently show that precisely the same murmur occurs in
exactly the same spot in the 9th month of pregnancy, when the
uterine tumour is so large as to preclude the possibility of reach-
AUSCULTATION APPLIED TO PREGNANCY. 151
ing the iliac vessels by pressure. Besides, the murmur is far too
loud and near-sounding to be so deeply seated. The most pro-
bable vessels appear to me to be the colica dextra and sinistra,
vessels not much smaller than a goose quill, and whose accom-
panying veins are very large. This idea is perhaps countenanced
by the effect of intestinal movements from flatulence or inspiration
in interrupting the murmur. The point, however, is open for
further investigation.
Though the subjects of the two preceding cases were single, the
murmur, it must not be forgotten, was perfectly identical in its na-
ture with that which authors describe as accompanying pregnancy.
This will be seen in the following cases.
Case 7. A female at St. George's Hospital in the eighth month
of pregnancy. By placing her completely on her side, and apply-
ing the stethoscope in certain parts, (probably the tract of a con-
siderable artery and vein,) but not in others, a murmur may be
produced at pleasure on either side ; and, further, by a gradual,
iirm depression of the instrument, this murmur may be made to
swell (exactly as in the internal jugulars) into a remarkably loud,
diffuse, continuous rumbling sound, augmented synchronously
with the maternal pulse.
The next case exhibits the circumstances attending the same
murmur with greater precision.
Case 8. Examined a woman at the St. Marylebone Infirmary,
Feb. 2, 1839. She was pale, ana3mic, excitable, with a pulse of
110, and in the middle of the ninth month of pregnancy. Over
the extent of a hand;s breadth on each side of the uterine tumour,
I could hear a very obscure and distant-sounding murmur, on a
key below a whispered who. It corresponded with the pulse, and,
though rather prolonged, was not continuous. I now turned the
patient completely over on her right side, so as to cause the uterine
tumour to gravitate away from the left os ilii, and leave a soft
space as broad as a hand between it and the anterior superior
spinous process. I passed the stethoscope gradually along it,
taking care to avoid the. tumour. On arriving nearly opposite to
the anterior superior spinous process, a continuous murmur with
augmentations corresponding to the pulse became perceptible, and,
with moderate pressure, gradually swelled to so great a degree of
loudness, that the midwife, though a stranger to the stethoscope,
could readily distinguish it. The key was that of a whispered
awe, it sounded close to the ear, and a slight degree of whistling
was 'mixed up witli it. On placing the stethoscope on either side
of a certain line, the murmur became inaudible, but it recurred as
often as I replaced the instrument upon the line itself. Moderate
pressure elicited the loudest murmur. Strong pressure diminished
it, and rendered it less decidedly continuous, — in consequence, I
presume, of nearly obliterating the vein. I" now made the patient
change sides, and I found exactly the same phenomena on the
opposite side, but rather less marked.
152 HOPE ON DISEASES OP THE HEART.
What was the seat of this loud continuous murmur ? Certainly
not the uterine tumour, as I carefully explored far from it. Un-
questionably the murmur was referable either to vessels of the
abdominal walls, (branches of the cireumflexa ilii artery and vein?)
or, what is more probable, to the colica sinistra, a branch of the
inferior mesenteric, and its veins, — the latter yielding the continu-
ous murmur, in consequence of being stretched by the weight of
the uterine tumour, and of being charged with attenuated blood,
and the artery supplying the usual augmentations. What was the
seat of the obscure, remote, low-toned murmur audible on the
uterine tumour itself? Probably, deep-seated veins and arteries, as
the common and external iliacs, compressed by the tumour. I sus-
pect this because, if it had been created in the uterine walls them-
selves by the act of pressure, it would, I think, have been on a
higher key and more near-sounding. At the same time, it is open
to investigation whether a murmur may not be excited in the large
veins and arteries of the uterine walls by mere pressure. I have
not at present cases to decide this point.
I subsequently examined three healthy patients with pulses of
sixty to seventy, and in the eighth month of pregnancy. In one, I
could barely distinguish the remote murmur on both sides of the
tumour, and in the other two I could distinguish no murmur what-
ever. Thus, we are not to expect the abdominal venous murmur
in all cases, and its absence will, I think, generally be found con-
nected with the thick, fibrinous blood of good general health, and
with the slow pulse that usually accompanies it.
Case 9. A female at St. George's, Feb. 4, 1839, in the fifth
month of pregnancy, pale and anaemic from late uterine hemor-
rhage. She was examined in the same way as Case 8, and pre-
sented exactly the same phenomena, but the murmur was not quite
so loud. Both in this and the other case, I tried every other part
of the abdomen, but nowhere else than at the points described on
either side, could I detect the loud continuous murmur.
3. The continuous murmur with little or no augmentations.
Case 7 was an instance of this. I think I have repeatedly heard
it ; but I cannot, at the moment, adduce other cases on which 1 can
depend.
Other tumours besides the gravid uterus may produce the re-
puted utero-placental murmur under consideration. On this point,
I shall gladly adduce the evidence of other authors, as they happen
to have supplied it.
According to Dr. Montgomery, abdominal tumours of any kind
may produce a murmur so exactly like the uterine souffle, that
" the nicest and most practised ear cannot detect any difference."
He quotes a case lately under his care, " in which enormous enlarge-
ment of the uterus, of that kind which has been called vascular
sarcoma, was accompanied by this phenomenon in its most perfect
condition ; and in another case of abdominal tumour, (supposed to
be of the spleen,) pressing on the aorta, this sound was equally dis-
AUSCULTATION APPLIED TO PREGNANCY. 153
tinct : moreover, it may at any time be imitated by pressing the
end of the stethoscope over the region of the iliac vessels."' (Cyclo-
ped. Pregnancy, p. 484.) M. Bouillaud, again, relates two cases,
in one of which " an ovarian tumour coincided with a bruit de
sovfflet exactly like that which occurs in pregnancy ;" and in the
second, a cyst of the right ovary presented a murmur, which was
decided by six or seven physicians and a number of students to
simulate the placental souffle so exactly that it was actually mis-
taken for it; the disease was pronounced to be an extra-uterine
pregnancy, a vaginal cesarian operation was performed, and the
patient died. (Traite, i. p. 248.)
These writers do not specify the particular kinds of murmur
which they heard; whether arterial, venous, or both ; but it is pro-
ble that they heard the several varieties in different cases.
The cases now offered are perhaps sufficient to establish the
fact that the reputed utero-placental murmur may exist wholly in-
dependent of pregnancy.1
The arguments are now to be examined which have for their
object to show that the murmur in question is necessarily seated
in the uterus.
Laennec, following Kergaradec, employs both negative and
positive reasons for maintaining this doctrine. He argues nega-
tively by excluding other sources of the murmur. The following
are his words. The " hypogastric (internal iliac) and primitive
iliac:' arteries are not the seat of the murmur, " because,'' says he,
" if such were-the case, it would exist on the two sides of the uterus
at once, or sometimes on one side and sometimes on the other, in
the same individual ; we could even occasion its production on the
one side or the other by varying the position of the subject, and
throwing the pressure sometimes on the artery of the left side and
sometimes on that of the right — the whole of which is not the case"
The preceding cases prove to demonstration that this illustrious
observer was in error. He argues positively, by adducing a state-
ment of M. Ollivry ; viz. that the murmur ceases "at the very in-
stant that ive cut the umbilical cord? — which fact Laennec pro-
nounces to be entirely decisive, It would undoubtedly be so, were
it true; but it lias been contradicted by Dr. Kennedy, an authority
not inferior to M. Ollivry. "Neither does the sound, says he,
invariably cease (as we might be led to conclude from Laennec's
statement on the authority of Dr. Ollivry,) on the separation and
expulsion of the placenta ; but, provided the uterine arteries at this
part, from imperfect contraction of the uterus, continue previous
to blood, a souffle will still remain, abrupt however, of short con-
tinuance, and w anting the lengthened terminating whiz observed
f1 I have at this time a patient under ray care who has an enormous
ovarian tumour, probably fibro-schirrous, which has existed for several years,
and upon ausculting over its inferior lateral parietes, at points correspond-
ing with the distribution of the right and left iliac arteries, a sound pre-
cisely similar to the utero-placental is perceived. — P]
in the perfect placental sound." (Dub. Hosp. Rep. v. p. 244, 1830.)
In short, the venous portion of the murmur ceases, and leaves the
mere arterial whiff. May not this change be the result of an altera-
tion id the volume of the uterine tumour, which is diminished,
indeed, by the expulsion of the foetus and placenta, but, in conse-
quence of the imperfect contraction of the uterus, is not wholly
reduced? May not the smaller size of the tumour suffice to pro-
duce the arterial whiff in vessels exterior to the uterus, though it
is insufficient to produce the venous murmur? I submit these
questions with diffidence; as it is only by one who is expert both
as an auscultator and an accoucheur, and who is also thoroughly
and dispassionately conversant with the phenomena of the venous
murmur, that they can be solved. If Dr. Kennedy could find
leisure to revise the subject, he would confer an additional benefit
on obstetric science.
Dr. Forbes states, in his Conclusion 4, that " the murmur ceases
immediately on the contraction of the utero-placental arteries, as is
proved in cases of death of the fcetus without delivery." This,
however, is also contradicted by Dr. Kennedy, who says that it
does not always cease on the death of the child, but u has its cha-
racter altered from the continuous murmur with its lengthy,
sibilous termination, to an abrupt, denned, and much shorter
sound." This is the arterial whiff as before, and apparently created
by the same circumstance — the diminished volume of the uterine
tumour, connected with the death of the child and commonly with
the rupture of the membranes.
To afford direct demonstrative proof that murmur does not exist
in the uterine arteries supplying the placenta, is not easy. Such
proofs would best be collected by auscultators who are also ac-
couchers, and to such I would beg to recommend the subject.
Meanwhile, it may be remarked, that the view which localises the
murmur of pregnancy in the utero-placental arteries, is not very
reconcilable with general analogy. Assuming, for a moment, that
the uterus is one of the erectile tissues, why is not its murmur
constant, as it is in the case of real erectile tumours, — such, for
instance, as varicose aneurism? If it be replied, with Laennec. that
the interposition of intestine might occasionally prevent it from
being heard for a few minutes, hours, or whole days, as Laennec
states, I would venture to rejoin that this explanation is unsatisfac-
tory; for any one may satisfy himself, by finding dulness on per-
cussion, that intestine positively is not interposed over a great
portion of the anterior and lateral parts of the fundus of the uterus.
If, therefore, a stethoscope were applied on any of these dull por-
tions, a murmur generated in the utero-placental arteries would
infallibly be heard through the solid medium of the abdominal and
uterine walls. It must be recollected, in exemplification, that a
murmur of the heart or ascending aorta can often be heard through
the whole thickness of the dorsal and even scapular muscles.
But if the uterus be not an erectile tissue, murmur in its arteries
AUSCULTATION APPLIED TO PREGNANCY. 155
ought to be amenable to the same general laws as regulate its pro-
duction in arteries in general. Now these laws point out that
arterial murmurs, when not created by local pressure, are restricted
almost entirely to thin-blooded subjects and to periods of vascular
excitement. But the utero-placental theory requires that the mur-
mur should exist in all subjects and on all occasions indiscrimi-
nately, and it does not assume that the murmur is created by local
pressure. Here then is an inconsistency.
Such are the reasons which lead me to believe that something
like the propositions with which I commenced this article (p. 147),
will ultimately be established as the doctrines relative to abdominal
murmurs connected with the gravid uterus, tumours, &c. 1 do not
pretend to have offered more than a general sketch or outline of
the subject, which the investigations of others will probably fill up
and correct.
Meanwhile, the immediate practical conclusions are as follows.
1. A near-sounding, high-toned continuous or venous murmur
with arterial augmentations, heard opposite to the anterior, superior
spinous process of the ilium and a little above, does not necessarily
indicate pregnancy, because it may exist in connection with other
tumours, and also wholly independent of any tumour. It occurs
almost exclusively in the thin-blooded or anaemic with a quick
pulse.
2. An obscure, distant, low-toned murmur, synchronous with
the pulse and not continuous, though sometimes rather* prolonged,
heard on a tumour in the hypogastric region, affords presumptions
that the tumour compresses the iliac vessels.
3. When either or both of the murmurs coincide with other
symptoms of pregnancy, they afford presumptions of this state, but
do not warrant an affirmation.
PART II.
INFLAMMATORY AFFECTIONS OF THE HEART AND
GREAT VESSELS.
This Part will be divided into four chapters. The first will be
devoted to inflammation of the external membrane (pericarditis) ;
the second, to that of the muscular substance (carditis) ; the third,
to that of the internal membrane (endocarditis) ; and the fourth, to
that of the internal membrane of arteries (arteritis). The close
connection subsisting between inflammation of the external and
internal membranes of the heart, — in other terms, the frequent
coexistence of pericarditis and endocarditis, will be pointed out in
the chapter on Pericarditis.
CHAPTER I.
ON PERICARDITIS.
SECTION I. — Anatomical characters of Pericarditis.
The anatomical characters of acute inflammation of the pericar-
dium are, 1. preternatural redness of the membrane; 2. coagulable
lymph adhering to its surface; and, 3. fluid effused within its
cavity. They will be treated of in succession, and at some length.
For, as the anatomical characters are an important key to the
symptoms, the latter cannot be understood, and, consequently, so
rapid and fatal a malady cannot be treated with the promptitude
and decision essential to the safety of the patient, unless the charac-
ters in question, and their intimate connection with the symptoms,
are thoroughly known to the practitioner. To this subject, there-
fore, I would particularly direct the attention of the student.
1. Preternatural redness of the Pericardium. — The redness is
seated partly in the serous membrane, but still more in the subja-
cent cellular tissue. It very seldom pervades the whole of the in-
flamed portion. It presents itself sometimes in numerous small
scarlet specks with a natural colour of the intervening membrane,
sometimes in spots of greater or less magnitude formed by the
agglomeration of the specks, sometimes in the form of arborescent
and stellated vascular injection, and sometimes in patches or diffuse
redness of considerable extent, formed by coalition of the spots, or
ANATOMICAL CHARACTERS OF PERICARDITIS. 157
thickening of the aborescent injection. Both the patches and
diffuse redness, however, have, almost without exception, a dotted
or mottled character. In a drawing before me, which I made from
a case of very acute and rapid pericarditis, nearly the whole of the
reflected membrane, underneath a layer of soft, primrose-coloured
lymph, is of a vivid, diffused, but mottled and dotted red (See the
writer's Morbid Anatomy, Fig. 54.) In some cases, according to
Laennec, though the inflammation, judging of it by the thickness
of the false membrane, had been very severe, scarcely any redness
exists. Such is the case, with respect to the surface of the heart,
in the drawing to which I refer. Here, it is to be presumed that
the redness existed during life, but vanished after death, as it is
wont to do in arachnitis, pleuritis, ophthalmia, and many other
diseases, when the inflammation is either very recent or only
slight — when, in other words, the blood has not yet become stag-
nant and impacted in vessels. This is important to be known, lest
the absence of redness should lead us to deny the existence of
pericarditis, or to imagine that the inflammation was confined to
the few spots to which lymph happens to adhere, — a mistake
which I have often seen committed.
When acute pericarditis degenerates into chronic, the redness
loses its brilliancy, sometimes becoming very deep and of a brown-
ish colour, and sometimes acquiring a cinnamon hue.
Redness alone does not afford conclusive evidence of pericardi-
tis, as all serous as well as mucous membranes are liable to vascular
injection from various causes independent of inflammation ; espe-
cially, obstruction to the return of the venous blood by valvular
disease, dilatation, softening, &c. ; the diseased, incoagulable state
of the blood in typhus, scurvy, purpura, &c. ; and imbibition of
blood effused into the pericardium in hemorrhagic pericarditis, of
which I have seen several instances. (See the writer's Morbid
Anatomy, Fig. 61.) In all these cases, indeed, the redness has a
more uniform intensity and a more abrupt outline, — in short, it is
more like a stain, than inflammatory redness. Still, as it is very
possible to mistake one for the other, redness should not be con-
sidered as affording conclusive evidence of pericarditis, unless con-
joined with an effusion of lymph or sero-purulent fluid.
As the sub-serous cellular tissue is softened by acute pericarditis,
the serous membrane admits of being peeled oft with preternatural
facility.
The pericardium, according to my observation, very rarely un-
dergoes thickening, and then, only in a slight degree: that which is
often regarded as thickening being, in general, nothing more than
superimposed and intimately adherent false membrane of old stand-
ing, and of opaque, bluish-white appearance. I have seen this ap-
pearance pervade the whole surface of the heart under a layer of
old, cinnamon-coloured lymph ; yet, after peeling off the lymph, I
could, by further scraping, remove the white layer also, without in-
juring the surface of the pericardium. (See ibid. Fig. 64.)
158 HOPE ON DISEASES OF THE HEART.
2. Coagulable lymph adhering to the surface of the pericar-
dium.— The inflamed pericardium secretes serum and lymph con-
jointly, and in a fluid state, from the same vessels. The process
may commence almost simultaneously with the inflammation. The
absolute and relative quantities of the serum and lymph vary
greatly in different cases. I have known serum secreted in such
quantity and with such rapidity, as to amount to a pint in twenty-
four hours : on the other hand, I have frequently found it so scanty,
especially in the early stage, as not to separate the surfaces of the
pericardium and prevent the sound of attrition, — a sound which they
yield, as will be hereafter explained, when roughened by adherent
lymph. Soon after the secretion has taken place, the lymph sepa-
rates from the serum by concretion, and adheres to the membrane.
A small proportion, however, generally remains suspended in the
serum in the form of flakes and filaments. The adherent lymph,
when recent, is of a pale straw colour, and of a soft, tender consist-
ence, becoming firmer and more tenacious as it grows older. Though
occasionally deposited in detached lumps and spots, the latter im-
parting to the surface a rough, papulated or granulated character,
it generally forms continuous layers, sometimes covering a por-
tion only, but more commonly the whole, or nearly the whole, of
the pericardium. The thickness of the deposition may vary from a
line to an inch ; but from a line and a half to three lines is its or-
dinary mean. Tts adherent surface is smooth ; the opposite is
rough and singularly figured. In drawings before me, where I
have delineated from nature all the appearances that I have ever
witnessed, the free surface is sometimes pitted with small depres-
sions at tolerably regular intervals, presenting the aspect of a fine
reticulation or of the section of a sponge. This occurs principally
where the layer is thin ; where it is thick, the surface is distributed
into more spacious cells, often as large as a pea, and separated by
coarser partitions. The partitions are sometimes irregular, being
higher and thicker in one part than another ; in which case the
effect exactly resembles that produced by separating two flat plates,
between the surfaces of which a layer of soft butter has been spread.
At other times the partitions are very regular; in which case, the
appearance, as Corvisart observes, is analogous to that of the second
stomach of a calf. Occasionally they are very thick and rounded,
and then they have the appearance somewhat similar to that of a
congeries of small earth-worms. Not unfrequently they are shaggy
and flocculent, hanging in shreds like tow. In one drawing, from
a case which had become chronic, no cells are apparent, but the
lymph is arranged in transverse, and, as it were, plaited wrinkles,
like undulations of sand on the sea shore.1
As coagulable lymph on other serous membranes does not pre-
sent these peculiar arrangements, except occasionally on the pleura,
1 The whole of these appearances are delineated in the writer's Morbid
Anatomy, Figs. 54 to 64.
ANATOMICAL CHARACTERS OF PERICARDITIS. 159
they must be referable to the perpetual movements of the pericar-
dium, or, as M. Bouillaud happily expresses himself, "to the inces-
sant repetition of the experiment above described, namely, the sud-
den separation of two surfaces overspread with a soft matter, of the
consistence of soft butter." The pleura is subject, though in a less
degree, to the same friction : hence it is, that it occasionally pre-
sents a honeycomb appearance. When lymph becomes old, it ac-
quires a deeper hue, varying from cinnamon to an intense brown-
red or mahogany colour. When of the latter colour, it usually
secretes bloody fluid, and, as well remarked by Laennec, it is to the
stain of this blood that the dark-red colour is attributable. He has
denominated such cases " hemorrhagic pericarditis. (Traite. ii.
654.)
The organisation of lymph sometimes takes place with astonish-
ing rapidity, as within the space of twenty-four hours — a fact which
has been ascertained by experiments on living animals, and by
pathological observation on the human species. The exceptions
I have generally found to occur either in very intense inflamma-
tion, when the violence of nature's operations would seem to coun-
teract their sanatory tendencies, or in atonic and cachectic subjects
of bad constitution, in whom the lymph effused is of an unhealthy
character and ill suited for organisation, just as we observe in the
case of external wounds affecting the same subjects.
Before describing the process of organisation and adhesion, let
us pause a moment to ask what is the object which nature pro-
posed to herself in the effusion of lymph. Unquestionably to effect
reparation : — the object for which the effusion is designed, in what-
ever part of the system it takes place. But how, it may be inquired,
can it effect reparation in the pericardium ? By causing adhesion.
Supposing that the inflammatory process does not terminate by
resolution — by the complete absorption of both lymph and serum,
the most desirable termination which remains is adhesion ; for,
should this not take place, the lymph becomes a secreting surface^
which effuses more and more lymph and serum, until, in a short
time, the cavity is completely distended, and the action of the
heart so embarrassed that a fatal termination speedily ensues.
But, should adhesion of the opposite surfaces take place, by which
further effusion is .prevented, life maybe prolonged for a considera-
ble period— even for years ; though, as will presently be explained,
the adhesion, so far from being a perfect reparation, gives rise to
another form of organic disease, which, in a vast proportion of
cases, ultimately proves destructive to the patient.
Adhesion takes place in some cases and not in others, — a cir-
cumstance which has been attributed to a difference in the quality
of the lymph, dependent on the greater or less energy of the in-
flammation, or on the more or less healthy constitution of the
patient, in consequence of which it possesses different degrees of
aptitude for organisation and adhesion. This explanation," though
not unsound, is less applicable to the pericardium than to otrTer
160 HOPE ON DISEASES OF THE HEART.
serous cavities ; for, here, the union or non-union depends also on
the absence or presence of fluid in the cavity ; the best lymph,
equally with the worst, being incapable of uniting when inter-
posed fluid prevents the apposition of the opposite surface. Hence
it is that a considerable extent of the pericardium often adheres,
while some portion, in which a little remains of fluid had accu-
mulated does not ; and this spot I have of late years observed to
be most frequently situated at the angle formed between the base
of the heart and the origin of the great vessels : for the same rea-
son it is, that, when the whole of the peritoneum is covered with
lymph, the intestines adhere to each other, but their adhesion with
the walls of the abdomen is prevented by the interposition of fluid.
Hence the immense importance, in pericarditis, of prompt and
energetic treatment in the first instance, in order, if resolution
cannot be effected, to cause absorption of the fluid, and thus afford
the opportunity for adhesion. Temporising indecision is inad-
missible ; for unless one or other of these terminations be induced,
the patient inevitably dies.
Such is the object of adhesion: we have now to describe the
process. It has already been stated that the organisation of the
lymph may commence within twenty-four hours. When the fluid
has been sufficiently absorbed, the layers of lymph on the opposite
surfaces of the pericardium come into contact, blend, and gradually
become united by vessels presenting themselves under the succes-
sive appearances of blood-stains, straggling lines, and, lastly, of
uniform pinkish vascularity, susceptible of injection from the peri-
cardium. The pinkness gradually diminishes, and with its dis-
appearance the organisation may be considered complete. The
depositions are thus converted into perfect cellular tissue, by which
the contiguous parts are more or less firmly, closely, and exten-
sively agglutinated. When adhesion is of recent standing, the
lymph is generally thick, and so soft as to be separable by mere
tearing into two layers, one adhering to each fold of the pericar-
dium. In proportion as the disease is older, the false membrane
is thinner and firmer, consisting, in cases that date several years
back, of the finest layer of dense cellular tissue. In some, even
this is not perceptible, the folds of the pericardium having become
amalgamated — apparently without the intervention of any mem-
brane, so as with difficulty to be separable, even by the scalpel.
(Case of May.) It is in such cases that pathologists have some-
times erroneously supposed the heart to be destitute of a pericar-
dium.
Such is the ordinary progress of adhesion ; but in some rather
protracted cases, generally of at least two or three months dura-
tion, where, though adhesion has been established, inflammation
has either recurred or never been completely subdued, an addi-
tional interstitial deposition of lymph takes place, which has been
known to thicken the adventitious mass to the extent of an inch
and upwards. In this case it sometimes possesses a laminated
ANATOMICAL CHARACTERS OF PERICARDITIS. 161
texture, the layers of which are progressively redder in proportion
as they are nearer the heart; and sometimes it exhibits different
degrees of consistence in different parts, one being almost liquid
and purulent, while another has the density of tubercular indu-
ration.1 Such cases are ordinarily fatal at no very remote period.
Adhesion is not always universal ; for, sometimes, though the
inflammation has pervaded the whole membrane, the depositions
of adherent lymph are only partial : sometimes, again, the inflam-
mation itself is only partial. In both these cases, the adhesions
are confined to the portions on which lymph was effused ; and
when these portions are limited, the adhesions are not close or
intimate ; for, as the gliding motion of the heart within the peri-
cardium is not prevented, it stretches the adherent lymph, and con-
verts it into long, loose bands of cellular tissue. But when the
portions overspread with lymph are extensive, partial adhesions
are sometimes close and firm, and the intervening parts of the peri-
cardium may be healthy and in contact. Instances occasionally
occur of adhesions being partial, though the layers of lymph are
universal; but here the parts not united are separated by purulent
fluid, thus constituting a series of small, detached abscesses around
the heart. Sometimes lymph is deposited in the form of small,
roundish, soft granulations, with which the pericardium is more or
less extensively studded.
Laennec is of opinion that pericarditis may sometimes be partial,
and confined even to a very limited portion of the membrane ; but
he adds that such cases are rare, scarcely amounting to one in ten,
unless white spots, presently to be noticed, be admitted as falling
under the head of partial pericarditis, which will greatly augment
the proportion. Partial pericarditis, he pursues, almost always ter-
minates in recovery and transformation of the false membrane into
long serous bands. (De l'Auscult. torn. ii. p. 655.) Without deny-
ing that pericarditis can be partial, I doubt whether this can be
proved ; since the signs, both general and physical, do not differ,
except in degree, from those of universal pericarditis, and since
adhesions may be partial though the inflammation have been uni-
versal, provided the layers of lymph happen to have been only par-
tially deposited. I lately, for instance, examined a heart presenting
several detached patches of recent lymph, yet the redness, and pro-
bably therefore the inflammation, was universal.
[Cases of pericarditis are often presented, in which the physical signs of
the disease, though well marked, are limited to a small space. — in which,
but little effusion takes place, and where the lung is not displaced by the
secreted fluid. These cases we have always regarded as being those of
local pericarditis; and we differ from the author, who appears to consider
that partial pericarditis cannot be proven to be of that character. — P.]
Pericarditis sometimes leaves no other vestiges than opake white
or milky spots, which are a well-known appearance on the surface
1 Latham, Lond. Med. Gaz. vol. iii. p. 5.
9— f 11 hope
162 HOPE ON DISEASES OF THE HEART.
of the heart. It is possible that they may be results of partial peri-
carditis, as supposed by Laennec, but there is no reason to suppose
that they may not also be occasioned in some instances by universal
pericarditis, as in the case referred to in the preceding paragraph.
The spots vary in extent from a few lines to two or three inches in
diameter ; their thickness is about that of the nail : they commonly
consist of a layer of false membrane, which has assumed the cha-
racter of condensed cellular tissue, and, with a little care, they may
generally be detached without injury to the pericardium beneath,
which is commonly somewhat injected, though not thickened.
But, though this is the ordinary cause of white spots, I have some-
times found them to be occasioned by hypertrophy of the sub-serous
cellular tissue, and even of the fibrous layer of the pericardium
itself; but I have never seen the serous layer so thickened and
opake as to present this appearance.
In concluding this account of the changes undergone by false
membrane, it may be added that, in conformity with the laws of era-
bryogony and of the scale of animals, false membrane, like cellular
membrane in general, is subject to i; analogous transformations"
that is, a change from the state of cellular tissue to that of fibrous,
cartilaginous, and osseous. Hence it is that we occasionally see
masses of cartilage and bone, sometimes of surprising magnitude,
connected with the exterior of the heart, as described in Chap. VII.
on osseous and other productions.1
3. Fluid effused within the cavity of the pericardium. — It has
been stated that serum is effused conjointly with lymph, from the
vessels of the inflamed pericardium, and that a separation of the
two takes place by the concretion of the lymph. The remaining
fluid is occasionally transparent, and either of a faint yellow more
or less tinged with green — as that of the interior of a lemon, or of
a pale fawn colour ; much more commonly, it is somewhat turbid
and cloudy from containing flakes, filaments and fragments of con-
crete lymph, which had not adhered in the form of false membrane,
or had been detached from the latter by friction and agitation f
occasionally, even in the first stage, it presents some degree of
milky opacity from an admixture of real pus; and in a very few
cases pure, creamy, greenish-yellow pus is effused without any
deposition of false membrane, (e. g. Case 4, of M. Bouillaud, vol. i.
336.) It will presently be shown that purulent effusion is more
common in the chronic stages. The quantity of fluid, though
variable and sometimes scanty, is in general considerable at the
commencement, that is, within the first two, three or four days of the
disease, — not unfrequently amounting to more than a pint. Corvi-
sart once found four, and Louis the same. It is speedily diminished,
[l M. Louis has recorded a case where a broad deposit of osseous matter
had surrounded the base of the heart. — P.]
[f If the lymph be intimately intermingled with serum, the exudation pre-
sents a whey-like, or milky appearance. — P.]
ANATOMICAL CHARACTERS OP PERICARDITIS. 163
however, by absorption when the first violence of the inflammation
begins to subside; and, after the lapse of a few days, it is, in the
majority of cases, not more abundant than the concomitant exuda-
tion of lymph. Sometimes, indeed, — even in very acute inflam-
mation, the absorption is so complete that no serum whatever is
found, while a copious exudation of thick, concrete lymph fills and
agglutinates the whole cavity. Laennec, observing this, asks with
his usual acuteness whether lymph may not sometimes be effused
in the dry state — a surmise which has since been established as a
fact by the occurrence of the sound of attrition of lymph in the first
stage of the diseases.
Should complete absorption of both the fluid and lymph not
take place, nor yet adhesion of the pericardium be established,
but the disease run on in the chronic form, the fluid, if previously
only serous or scro-flocculent, gradually becomes more milky and
opake, until it eventually assumes a perfectly sero-purulent cha-
racter. This results from the tendency exhibited by inflammations
in general to secrete pus in their chronic stages. Rarely, however,
is perfect pus found in the pericardium; — probably because the
patient dies from irritation before the suppurative process is fully
established. Not unfrequently the fluid is bloody (Cases of Porter
and Snowden), and the lymph of a red colour. (Case of Porter.)
This is attributable to the tenderness of all newly organised struc-
tures, in consequence of which they are apt to become congested
and to effuse blood when siibjected to any unusual irritation or ex-
citement, a phenomenon witnessed daily in external ulcers.
[In thirty-seven cases of pericarditis, Louis found that the effusion was
sero-sanguinolent in five, serous in nine, sero-purulent in fifteen, and true
pus in seven. — P.]
Compression exercised by fluid sometimes reduces the volume
of the heart, and renders it, as it were, atrophous. Bouillaud
relates cases in which the same was effected by "enormous masses
of false membrane." (Traite, i. 448.)
[If the effusion remains unabsorbed for some time, hypertrophy and dila-
tation of the heart is more common than its atrophy, being produced by the
increased action of the muscular structure. — P.]
Such are the anatomical characters of acute pericarditis, both
in its early and its advanced or chronic stages. It remains for me
to make a few remarks on that form of pericarditis which appears,
from the mildness of the inflammatory symptoms, to have been
chronic from the first. Its anatomical characters do not differ very
materially from those exhibited by the advanced stages of the acute
form. The inflammation always pervades the whole of the cavity;
the redness is deeper and duller than in the acute affection ; false
membranes are, in many cases, totally deficient ; and when pre-
sent, they are thin, soft and fragile, as if wasted by suppuration :
finally, there is always a more or less abundant effusion of turbid,
flaky, milky, and sometimes completely puriform fluid. Intimate
IV
L64 HOPE ON DISEASES OF THE HEART.
adhesions of the pericardium to the heart may follow the absorption
of this fluid; but M. Laennec does not appear to me to be borne
out either by facts or by analogy, when he supposes that chronic
pericarditis is the sole cause of intimate adhesion, and that the acute
affection only gives rise to loose adhesion by more or less elongated
bands. According to my experience, the latter is the more frequent
cause of intimate adhesion. (Cases of Copas, May. and many others
after acute rheumatism.)
In scrofulous and phthisical individuals, tubercles are some-
times developed in the false membranes of pericarditis, and, accord-
ing to Laennec, they may cause the acute to pass into the chronic
state, as frequently happens in the case of pleuritic and peritoneal
false membranes.
The muscular substance of the heart is sometimes not affected
by pericarditis ; but sometimes it is rendered redder or paler,
browner or yellower, harder or softer and more lacerable, than
natural. These changes result from inflammation propagated from
the pericardium to the muscular substance, as will be fully shown
in the article Softening.
As endocarditis co-exists with pericarditis in the immense ma-
jority of cases, the practitioner must not neglect to extend his
observations, in cases of pericarditis, to the interior of the heart,
where he will generally find tumefaction and constriction of the
valves, redness of the lining membrane, coagula, (fee, as will be
fully explained in the chapter on Endocarditis.
SECTION II.-— Signs and Diagnosis of Pericarditis.
There is no inflammatory affection of which the diagnosis has
been considered more difficult than pericarditis. Corvisart states
that very acute pericarditis is often completely concealed, and that,
of chronic pericarditis, he "has always found the diagnosis difficult,
and sometimes very obscure." Laennec states that he has often,
on dissection, discovered the disease in a severe form, when nothing
had afforded a suspicion of its existence ; and, on the other hand,
that he has frequently witnessed all its signs, without finding a
vestige of the malady. He adds that he has seen this double mis-
take committed by the most expert practitioners, and he therefore
concludes that pericarditis can only be guessed at (devinee), not
detected (reconnue). Dr. Latham mentions two cases of what
appeared to be, and was treated as, marked inflammation of the
brain ; yet this organ was found perfectly sound, and the heart
affected with intense pericarditis. (Lond. Med. Gaz. vol. iii. p. 209.)
Andral relates a similar case. (Clinique Me.dical, vol. iii. p. 444.)
Others have more recently been published by Dr. Macleod in the
Med. Gaz. It is proper to keep these difficulties prominently in
view, in order that practitioners may be better prepared to contend
with them. But it must be added that such cases as those of
ANATOMICAL CHARACTERS OF PERICARDITIS. 165
Latham and Andral are very rare ; and that, with the improvements
in diagnosis introduced by modern research, the disease may, I feel
assured from numerous post-mortem examinations, be nearly always
detected. Since I wrote the preceding sentence, nine years ago,
new lights have been thrown on certain of the physical signs, which
have rendered the diagnosis still more precise and certain.
I shall first enumerate the general signs, and then endeavour to
point out the causes of their obscurity, the means of rendering
them available, and the diagnosis from other inflammatory affec-
tions of the chest. The physical signs will subsequently be con-
sidered.
General Signs} They are as follows : acute inflammatory
fever [generally preceded by rigors]; sometimes a pungent, burning,
lancinating pain in the region of the heart, shooting to the left sca-
pula, shoulder and upper arm, but rarely descending below the
elbow, or even quite to it. The pain is increased by full inspira-
tion, by stretching the left side, by percussion, and especially by
pressure between the praecordial ribs, and forcing the epigastrium
upwards underneath the left hypochondrium. In other cases, the
pain is more or less dull, and does not lancinate : occasionally, it is
wholly absent, or is merely an uneasiness.2
[Many patients lefer the pain to the epigastrium or left hypochondrium,
rather than to the praecordial region : this pain, which is circumscribed, is
1 By General Signs, I mean all those not furnished by percussion and
auscultation, which latter I shall call physical. The more refined subdi-
visions which some have preferred, are perplexing without answering any
object.
2 M. Bouillaud says, " I have done my utmost to discover some satisfactory
reason for this sort of inconstancy in the pain of pericarditis. The results
of a comparative examination of a good number of cases are — 1. That the
most simple pericarditis is precisely that in which pain is wholly absent, or,
at least, but slightly felt. 2. That rheumatic pericarditis also is often free
from pain, or at least but very slightly painful, if there is no pleurisy. 3.
That in this last complication, there is most frequently, though not always,
such a pain as I have described, especially when the pleurisy occupies the
left side ; and that this pain is never more acute, more poignant, in short,
more dreadful {atroce), than when the pleurisy is seated on the left side of
the diaphragmatic pleura." (Traile, i. 453.) I have made researches simi-
lar to the above, more especially during the last eight years ; and I have
certainly found that, in the great majority of cases, the pain was either wholly
absent, or of a mild, endurable kind; yet I have occasionally seen it more
considerable, in the absence of pleuritis, than M. Bouillaud seems to intimate.
I therefore think that further observation will be requisite before we can
come to the conclusion that a pleuritic complication is the sole cause of con-
siderable pain in pericarditis, though it may be of the dreadful (atroce) pain
which he describes, and of which he has given two or three instances — one,
in the distinguished orator Mirabeau. M. Andral observed " acute, dread-
ful, rending pain;' (vive, atroce, dechirante) in one case (Clin. Med. iii.
416), and M. Louis found "acute pain15 (douleur vive) in two cases (Mem.
on Pericarditis); yet in all these instances there was no pleurisy. I have
not searched for other cases, but Louis estimates that there is pain in one
half.
166 HOPE ON DISEASES OF THE HEART.
exasperated by upward pressure. In some cases, the sensation complained
of is extreme constriction over the left side, with oppression in the region of
the heart, rather than acute pain. — P.]
The next symptoms are, inability of lying on the left side, and
sometimes in any position but one, which is most commonly on
the back; dry cough ; accelerated respiration [which is short and
laborious, occasionally interrupted by sighs and hiccup] ; pal-
pitation of the heart, the impulse of which is sometimes violent,
bounding and regular, though its beats may, at the same time, be
unequal in strength ; at other times it is feeble, fluttering, intermit-
tent, irregular and unequal ; [sometimes the pulse at the onset is
unaffected, or slower than natural,] pulse always frequent, and
generally, at the onset, full, hard, and abrupt, or even jerking, but
regular. Sometimes it maintains these characters throughout, but
more commonly it becomes, after a few days, weaker than accords
with the strength of the heart's action, and, in the worst cases,
small, feeble, intermittent, irregular and unequal, in accordance
with similar action of the heart. Occasionally it possesses the lat-
ter characters from the commencement ; whenever they exist, they
are accompanied by dyspnoea; a constrained position, deviation
from which induces a feeling of suffocation; extreme anxiety both
of countenance and mind; a peculiar drawn or contracted appear-
ance of the features, [indicative of great distress,] or is occasionally
accompanied with the sardonic grin; faintness, paleness, failure of
animal heat, constant jactitation, insupportable distress and alarm,
cold perspiration, and, finally, from obstruction of the circulation,
intumescence and lividity of the face and extremities. I have seen
extensive oedema of the feet supervene during the last twelve hours
of life. Delirium and convulsions are also occasionally seen in the
last stage, being" results of cerebral congestion and of the circulation
of venous blood.
Such is the category of symptoms of pericarditis. One cause of
their obscurity would, at first sight, appear to consist, and by Cor-
visart, Laennec, Louis, and pathologists in general has actually
been found to consist, in their diversified, incongruous, and vari-
able nature. The pulse, for instance, displays, at one time or other,
almost every kind of character; the disease, though the inflam-
mation be equally intense, is sometimes very supportable, — at
others, agonising : in one case it terminates fatally in two or three
days, — in another it lasts as many weeks!
[Although in the more violent cases of pericarditis the symptoms enu-
merated may be presented, yet, in a large number of instances the descrip-
tion is inapplicable. Often, does pericarditis exist without producing in the
chest any unusual sensation, the rational signs of the disease may be want-
ing, the affection be entirely latent, and without the aid of physical diagnosis,
the pathological condition could not be discovered.— J*.]
Now, in reality, these diversities, while they do not render the
symptoms less pathognomonic of the disease in general, as will
presently be shown, are, according to my observation, invaluable
ANATOMICAL CHARACTERS OF PERICARDITIS. 167
indications in another point of view — they contribute to denote the
nature and progress of the anatomical changes of structure, and, in
correspondence, the progress and exact state of the malady. For
it is a fact of which I feel well assured from long observation, that
a difference in the quality and quantity of the effusion imparts a
totally different aspect to the symptoms. Thus, when, either from
the effusion consisting principally of coagulable lymph, or from the
simultaneously secreted serum being rapidly absorbed, universal
adhesion of the pericardium promptly takes place, preventing all
further fluid effusion, the action of the heart maintains throughout
much the same vigour and regularity as it manifested at the onset
of the malady, and the pulse exhibits corresponding characters of
strength, hardness and regularity.1 Under these circumstances
also, the position is less constrained, and less pain is produced by
an unfavourable one; in consequence, perhaps, of the heart being
curbed by the adhesion, and thus prevented from impinging with
the same degree of violence against the thoracic walls. Finally,
as the force and rhythm of the heart's action, and consequently the
circulation and respiration, are adequately maintained, the life of
the patient will be prolonged probably for weeks, even though the
inflammation remain unsubdued, and, if he sink at all from the
immediate effects of the disease — of which I have never had an
instance in my own practice, he will sink apparently from mere
exhaustion by the effects of protracted irritation. Now this is a
very supportable form of disease, and it is still more supportable if,
instead of proceeding to adhesion, it undergo resolution by the
effect of remedies, — which is a very common result under the treat-
ment hereafter to be described.
But the case is very different if, instead of adhesion or resolution
taking place, there be a copious serous effusion remaining unab-
solved. The heart's action is then mechanically embarrassed by
the compression exercised by the fluid, — a compression which is
the more considerable from a double cause: first, because the effu-
sion is sudden, and organs do not so easily accommodate them-
selves to sudden as to gradual compression; secondly, because the
pericardium, deprived of its distensibility by inflammation, is inca-
pable of yielding as the fluid accumulates. Hence the heart, unable
to transmit — perhaps even to receive, the blood, flutters, intermits,
beats feebly, irregularly, and unequally. The pulse has corres-
ponding characters, and is sometimes scarcely perceptible. From
this failure of the circulation through the heart, result its usual
symptoms: namely, faintness, dyspnoea, anxiety, coldness, lividity,
a sense of suffocation on the slightest deviation from a certain posi-
tion, with all the other symptoms of an extremely obstructed circu-
1 Since I wrote the above, Dr. Stokes has recorded four or five fatal cases
in which the effusion consisted almost entirely oflymph. (Dublin Jour. vol.
iv. p. 29); and he supports the doctrine broached in the text.
168 HOPE ON DISEASES OF THE HEART.
lation. If this state be not expeditiously relieved by remedies, the
patient dies in the space of a few days or even hours.1
Should the fluid be copious from the first, this series of symp-
toms will make its appearance equally early ; but, in general, two,
three, or four days elapse before the accumulation becomes con-
siderable ; in which case the former series — those attended with
strong and regular action of the heart, will exist during this period,
and will then be suddenly replaced by the latter. In a few in-
stances, I have found the latter exist when the quantity of fluid
was inconsiderable, but that of lymph enormous. I conceive, there-
fore, that an enormous accumulation of lymph has the same effect
as fluid in embarrassing the action of the heart. I have also found
the worst class of symptoms occasioned by a less quantity of fluid
in some cases than in others, — a difference which probably depends,
in some cases, on diversities in the nervous irritability; but, in
others, I suspect that it is connected with the simultaneous exist-
ence of carditis ; for, when the affection has been thus complicated,
I have known the feeble, fluttering action of the heart and all its
concomitant train of unfavourable symptoms, occur, though the
effusion within the pericardium was inconsiderable; and it is rea-
sonable to suppose that, when the heart is softened by inflammation,
its contractile power would be so far impaired as to render it inca-
pable of transmitting its contents. In others, again, the worst class
of symptoms may result, according to M. Bouillaud (Traite, i. p.
463, &c), from polypous concretions in the heart, occasioned by
co-existent endocarditis. Though I have never had the opportu-
nity of personally ascertaining this by post-mortem examination, I
can easily understand and believe it. The peculiar expression
and sardonic contortions of the features attending the worst class
of symptoms, are occasioned by the sympathy subsisting between
the respiratory nerves of the face and those of the heart ; or, if it
be not premature to recognise the universal true spinal or excito-
motory system, they are occasioned by the incident or excitory
filaments of the pneumogastric nerve transmitting an excited im-
pression to the true spine, whence it is reflected on the face by the
reflex or motor filaments of the portio dura, and portio minor of the
Trifacial.2
1 It is instructive to observe that the same class of symptoms is induced
under whatever circumstances the circulation through the heart is extremely
impeded : thus, I have seen them result from poisoning by arsenic, and from
intense gastro-enteritis : they result also from poisoning by the concentrated
mineral acids, by tobacco, &c. — all of which agents have a paralysing effect
on the heart. I have likewise seen them occasioned by polypi forming in
the heart before death (see Polypus) and by extreme softening of the organ.
(See Symptoms of Softening.)
* M. Bouillaud explains the great differences in the general symptoms of
pericarditis in another way, which to me does not appear satisfactory. Hav-
ing observed certain cases, (especially Case 5, i. 345,) in which pericarditis
complicated with diaphragmatic pleurisy presented the most frightful series
ANATOMICAL CHARACTERS OF PERICARDITIS. 169
Such are the causes of the general symptoms. It will now be
apparent that their variability is calculated to enlighten, rather
than to perplex the practitioner, and that, whatever aspect they
of general symptoms; and having observed other "cases of very intense
pericarditis in which these frightful symptoms scarcely existed at all," he
comes rather precipitately to the conclusion that " the severe general symp-
toms (les grands accidents de reaction) observed in certain cases of peri-
carditis, ought to be considered as appertaining more directly to a violent
pleuritic or pleuro-peripneumonic complication than to the pericarditis itself;
since these severe symptoms may be wholly absent in pericarditis exempt
from so serious a complication, and, on the other hand, we may see them
burst out in exceedingly acute pleurisies and pleuro-peripneumonies, (espe-
cially diaphragmatic.) without co-existent pericarditis." (Traite, i. 463.)
There is no doubt of the fact that pleurisy and pleuro-peripneumony, espe-
cially diaphragmatic, may produce the violent symptoms in question: of this,
I have myself seen repeated instances : it is therefore obvious that these
complications might aggravate the symptoms of pericarditis, and raise them
to their utmost intensity; but it does not follow, on this account, that all
cases of pure pericarditis should be exempt from severe symptoms. Nor
are they : for I have already quoted Andral and Louis' cases (p. 166,) to
prove that the pain may be dreadful, and I have shown that when the circu-
lation through the heart is suddenly and extremely impeded, not only by
diseases of the organ itself, as compression by much fluid within the peri-
cardium, carditis with softening, and polypus, but also by nervous paralysis
of the heart from poisons, intense gastio-enteritic inflammation, &c, the
worst symptoms of fainting and apncea with overwhelming anxiety and
" nervous reaction" may be induced. M. Bouillaud, indeed, seems to admit
this by implication — never, however, forgetting his favourite pleuritic affec-
tion : for he says "the phenomena of dyspncra carried to suffocation, and
those of faintness carried even to syncope, coincide, if not always, at least
most frequently, with an immense effusion in the pleura and the pericardium,
and with the formation of polypous concretions in the cavities of the heart.
The extension of the inflammation to the fleshy fibre of the heart and the
inflammatory tumefaction of the valves, are also incidental circumstances
attending pericarditis to which we must attribute an important participation
in the reactional phenomena, and particularly in the disturbance of the cir-
culation and respiration." Traite, i. 462.)
M. Bouillaud has here enumerated circumstances enough (and they are
those specified in the text) to account for the worst class of general symp-
toms attending pericarditis, without being driven to the necessity of ascribing
them almost entirely to a pleuritic or pleuro-pneumonic complication. I
shall, in conclusion, cite a passage from a valuable paper on pericarditis by
Dr. Stokes, (Dublin Journal, vol. iv. p. 54, 1834.) who exactly corroborates
the view which I have for the last eight years maintained in the text, re-
specting the principal cause of the diversities in the symptoms of pericarditis.
"I shall now give," says he, " the results of my experience on this interest-
ing and important subject. It would appear, that much of the confusion
that has existed with respect to the diagnosis of pericarditis, has arisen from
not separating the consideration of that form of the disease, in which there
is a copious liquid effusion, from that in which the surfaces of the pericar-
dium are only separated by an exudation of lymph. It will be found, I
think, that the general symptoms of these two varieties are often exceed-
ingly different, and that those cases which most often prove fatal, with that
assemblage of distressing symptoms noticed by all authors, more frequently
belong to the first species ; while the second is often, as far as external
symptoms go. a nearly latent affection."
170 HOPE ON DISEASES OF THE HEART.
assume, they would still be abundantly sufficient, did no other
difficulties interfere, to render the disease one of easy diagnosis,
even without the aid of auscultation. But there are other diffi-
culties which render that aid indispensable. These consist partly
in the absence or mildness of some of the most important symp-
toms, and partly in the presence of pulmonary complications. I
shall notice them in succession.
When pain in the immediate situation of the heart, increased
by pressure in the interspaces between the ribs or upwards under
the left hypochondrium, is accompanied by increased action of the
organ and fever, there can be little doubt of the existence of peri-
carditis. But sometimes, and not unfrequently, pain is slight or
totally absent ; in which case, the practitioner must carefully
employ pressure as above directed; and if, notwithstanding, no
pain is Felt by the patient, he must carefully turn his attention to
the remaining symptoms. Should the pulse be feeble, faltering,
intermittent, unequal, &c, without any apparent adequate cause,
(and it is well known to practical men that such a pulse rarely if
ever exists in ordinary cases without an obvious cause,) this sign,1
especially if attended with the usually concomitant signs of an
obstructed circulation, affords evidence of the strongest description;
and the evidence is greatly augmented if there be increased dulness
on percussion, indicating effusion within the pericardium.
But there may neither be pain, nor an unsteady pulse, nor its
usually attendant disturbances of circulation and respiration. In
this case, should the action of the heart be violent and of a bound-
ing or jerking nature without any manifest cause, — especially
organic disease of the organ ; and should it be accompanied by a
greater degree of fever and anxiety than can be accounted for by
any other existing complaint; finally, should it be attended with
certain murmurs presently to be described, the physician will sel-
dom be wrong in diagnosticating pericarditis.2 The presumption
1 On it alone I saw M. Chomel found a successful diagnosis in the last
stage of a typhus fever, when the symptoms were extremely complex. I
have delineated the heart in fig. 61 of my Morbid Anatomy.
2 The three signs above enumerated, namely, increased action of the
heart, fever, and a murmur which did not previously exist, are the' least
number that suffice (and they are often amply sufficient) to indicate inflam-
mation of the heart; and I shall hereafter show that we may generally
decide by the nature and situation of the murmur, whether the inflammation
is pericarditis, endocarditis, or both. M. Bouillaud, finding difficulty in
accomplishing this (Traite, i. p. 465), adds a fourth sign as indicative of
pericarditis in particular: namely, dulness on percussion. He says, "But
we have seen that the embarrassments of circulation and respiration may be
deficient: the question then is, to know whether, in their absence, the dia-
gnosis of pericarditis is still possible. I answer that it is, and that dulness,
with or without prominence, of the precordial region, plus the signs fur-
nished by auscultation, in an individual who has fever, and who previously
presented no signs of organic disease of the heart, are certain symptoms of
pericarditis" (Traite, i. p. 464). Dulness is a valuable sign, but it is often
absent; yet I repeat that, in its absence, the diagnosis may still be formed
by the nature and situation of the murmur?.
ANATOMICAL CHARACTERS OF PERICARDITIS. 171
is still stronger if, when the symptoms supervene, the patient is
affected with acute or subacute rheumatism, — an affection which,
whether severe or mild, whether in its early or its latter stages, is,
beyond comparison, the most frequent cause of pericarditis and
endocarditis.
[M. Bouillaud insists (see note) and with great reason, on the importance
of a fourth sign in the diagnosis of pericarditis; namely, dulness, with or
without prominence of the precordial region. The attention of pathologists
was first called to these signs by Monsieur Louis : they are exceedingly
precious, and as they exist in a vast proportion of the cases of pericarditis,
they render the diagnosis infinitely more certain. The dulness of the
precordial space, which is first due to the Uirgescence of the heart, becomes
very marked by the effusion of fluid into the pericardium, the precordial
region in a corresponding part is elevated, and the respiratory murmur is
there obliterated. In fact, we may say with M. Louis, " that the sudden
occurrence of a sharp pain in the precordial region, preceded by chill and
fever, and accompanied with palpitation and dyspnoea, absence of respira-
tion and of sound in the precordial space, in a person previously in good
health, are almost positive evidences of the existence of the disease in
question.''
The pulse may be, either regular or intermittent; in the latter case,
disease of the lining membrane of the heart may be diagnosticated. As
regards pain, that is very variable; — it will be seen that it is sometimes
entirely absent. — P.]
It was an opinion of Corvisart that the most acute cases were
the most obscure, because, says he, "the attack is abrupt, the
progress rapid, and the termination almost sudden." This obscurity
was felt by that acute observer, because he was not acquainted
with any signs of the disease on which he could depend but the
feeble, unsteady pulse, the anxiety, dyspnoea, lividity and other
symptoms dependent on obstruction of the circulation, — symptoms
which did not always show themselves early enough to afford him
data for the diagnosis before the case was hopeless. At present,
however, when we are in possession of so many signs, the same
obscurity does not exist. 1 have seldom experienced much diffi-
culty in recognising the acute pericarditis to which Corvisart refers.
The most obscure cases are those mentioned by Latham and Andral,
in which a fictitious inflammation of the brain or any other organ
diverts the attention from the heart, and the delirium of the patient
renders it impossible to obtain information from himself. Still,
when apprised that such cases exist, I should think it perhaps not
impossible to provide against them. If, for instance, it were the
general practice (one which I invariably pursue myself1) to place
the hand on the prascordial region as well as on the pulse in every
severe inflammatory or febrile affection, in the same way that we
daily feel the abdomen in cases of fever, even though the patient
make no complaint of it, we should seldom fail to find an inordi-
nately increased impulse or some other anomaly in the action of
1 I observe, that Dr. Elliotson has made an identical remark in his Lura-
leian Lectures — a work which I had not seen when the above was published.
172 HOPE ON DISEASES OF THE HEART.
the heart, which would lead us to make, by auscultation, &c, a
regular and probably successful investigation for pericarditis. For
there can be little doubt that the symptoms, in the cases alluded to,
are in reality not absent, but merely masked by others of predomi-
nant severity.
The only remaining cause of obscurity is, inflammation of some
of the thoracic viscera, particularly the pleura, the pain of which
may be seated over the heart. These complications, to which
Corvisart ascribed the main difficulty of detecting pericarditis, will
now cause little embarrassment to those who are acquainted with
auscultation.
Pleurisy may, in addition to its ordinary symptoms, be detected
by dulness on percussion, beginning below and extending upwards ;'
respiratory murmur diminishing or wholly failing in the same pro-
portion, namely, as the fluid ascends and compresses the lung;
bronchophony and bronchial respiration, the former passing into
aegophony when there is a moderate quantity of fluid in the cavity;
and diminution or total absence, over the dull part, of the vibratory
tremour communicated to the chest by the voice. Peripneumony
may, in addition to its ordinary symptoms, especially pink or rust-
coloured, viscous sputa, be recognised in its first stage by crepitant
rale with commencing dulness on percussion : in its second stage
or hepatization, by cessation of crepitant rale and respiratory mur-
mur; distinct dulness on percussion : bronchophony and bronchial
respiration, diminished respiratory movement of the affected side,
and increased vibratory tremour of the voice. Finally, bronchitis
may be known by the mucous, sibilous and sonorous rales. Should
none of these signs be present, the negative evidence thus obtained
fixes the disease on the heart ; should they be present, the diagnosis
of the pericarditis must be made by a general comparison and cau-
tious consideration of all the symptoms, especially the murmurs of
the heart and the dulness on percussion ascending in the direction
of the pericardium. If a doubt should remain, which it seldom
will, I should recommend a treatment addressed to the heart, and
at the "same time suited for the pulmonary complications ; for even
the possibility of a mistake should not be admitted in reference to
an organ, where, if the cure be not complete, the consequences
may be irreparable.
The diagnosis of endocarditis, when complicating pericarditis,
[which is extremely frequent] will be pointed out under the phy-
sical signs of the latter, and in the chapter on Endocarditis.
Signs of Amelioration. In a disease the treatment of which
requires so much decision and promptitude in the practitioner as
pericarditis, it is necessary for him to be thoroughly conversant
[l Percussion in pericarditis would yield a flat, or obscure sound in a
space following the shape of the pericardium; whilst the dulness arising
from effusion in pleuritis would not have any specific outline. — P.]
ANATOMICAL CHARACTERS OF PERICARDITIS. 173
with the symptoms, not only of deterioration, but also of ameliora-
tion. To these, therefore, I shall advert.
If the worst symptoms decline, namely, the feeble, fluttering,
unsteady pulse and impulse of the heart, the feeling of faintness
and suffocation, and the constrained position to which that feeling
confines the patient, we may be tolerably sure that the fluid, on
which these symptoms commonly depend, is decreasing by absorp-
tion ; and the evidence is almost positive, if there be also a com-
mensurate diminution of morbidly extensive dulness on percussion.
But, notwithstanding, should pain, increased impulse, fever, anxiety,
and a murmur of pericardiac attrition continue, the inflammation is
in progress, is adding to the accumulation of lymph, and is possibly
tending to the effusion of purulent fluid. But should the pain,
instead of being fixed and pungent, become a mere diffuse uneasi-
ness, or wholly cease ; should the anxiety decrease, the murmur of
attrition become inaudible, and the peculiar vehemence of the
heart's action gradually degenerate into the beat of a merely
accelerated circulation, the inflammation may be presumed to be
on the decline; but it is not until all these symptoms have com-
pletely ceased, that it can safely be said to have terminated.
Still, lymph and adhesion of the pericardium may remain, ren-
dering the reparation imperfect; and such we may consider to be
the case if, with every advantage of perfect tranquillity and absti-
nence, the motions of the heart do not> in due time, completely
regain their natural standard, and still more if, on very gradually
returning to corporeal exercise, the patient find himself, after an
adequate trial, incapable of his wonted exertions in consequence of
palpitation and shortness of breath. If the case was complicated
with endocarditis, and a valvular murmur remain, more or less
incapability of exertion is to be expected as a necessary and perma-
nent effect, since the patient labours under valvular disease.
Physical Signs. — Percussion. When the pericardium contains
more than half a pint of fluid, the resonance of the precordial
region becomes dull over a greater extent than natural, in propor-
tion to the quantity ; and I have observed, though I know not
whether others have remarked the same, that the dulness mounts
higher up the sternum, in the direction of the great vessels, than
when it is occasioned by mere enlargement of the heart.1 The
impulse also, it may be added, is undulatory, and not exactly coin-
cident with the first sound, in consequence of the heart having to
displace the fluid interposed between it and the thoracic walls,
before it can impinge against the latter, when .the patient is in the
horizontal position (Vid. Hydropericardium). Further, the first
sound and any murmurs generate in the auricular valves are more
obscure than natural, in consequence of having to be transmitted
[' la pericarditis, respiration is absent when the precordial region is
elevated ; but, in the cases of mere enlargement of the heart this is not
observed. — P.]
174 HOPE ON DISEASES OF THE HEART.
through a mass of fluid and lymph: the second sound maybe
heard high up the vessels almost as distinctly as natural. M. Louis
states that he once found a temporary effusion of fluid attended
with a prominence of the cardiac region, but lie is not sure that
the prominence did not previously exist. I do not happen to have
noticed a prominence from this temporary cause, but I think it not
improbable in young subjects in whom the cartilages are flexible.
Dulness on percussion is a sign of the first importance in peri-
carditis.
The impulse of the heart is [at first] increased, sometimes
greatly : — not only heaving the thoracic walls vigorously, but being
remarkable for its abrupt character : whence it often visibly shakes
the whole anterior chest. Some beats are generally stronger than
others, even when the action is regular. Such is the nature of the
impulse so long as there is little or no serous effusion, and it is
apparently attributable to an increase of irritability in the organ,
resulting "from inflammation. But when considerable serous effusion
takes place, and by compression embarrasses the action of the heart,
the impulse is feeble, faltering, irregular, and unequal. When peri-
carditis is attended with aortic regurgitation from endocarditis, the
pulse or rather throb of the arteries, often perceptible over the whole
body, is of a remarkable nature, each undulation of the blood shoot-
ing with velocity under the finger, as if through a lax or imper-
fectly filled tube, and constituting what is called a jerking pulse, —
the pulse that we feel during reaction after uterine or other excessive
hemorrhage. Very frequently, it is accompanied with a distinct
thrill. Sometimes it is stronger and more voluminous, at others,
smaller and weaker ; yet, in the latter case, it still retains the same
jerking character.1 If the injury of the aortic valves and consequent
regurgitation remain uncured, the jerking pulse is permanent.
The Sounds. Two classes of murmurs, derived from two dis-
tinct sources, may attend pericarditis. I shall notice them in
succession.
The first class are direct signs of pericarditis ; for they result
from attrition of the opposite surfaces of the pericardium roughened
by lymph, and also, in some cases, from the roughened surfaces
agitating or churning a little serum between them. The murmurs
are, further, attended with a vibratory tremour generally perceptible
to the hand. Dr. Stokes found this tremour in five cases out of
six. I have noticed it several times. Dr. Watson mentions it
once (Med. Gaz. April 11, 1835). These phenomena only exist,
1. at the commencement of pericarditis, before any considerable
liquid effusion has taken place; 2. in cases of what has been
denominated dry pericarditis, that is, with effusion of lymph alone;
1 When I wrote the above paragraph in the first edition of this work, I was
under the impression that the jerking pulse was connected more with the
pericarditis than with the regurgitation, which latter I. subsequently ascer-
tained to be its sole cause. Its connection with this cause had not previously
been noticed.
ANATOMICAL CHARACTERS OF PERICARDITIS. 175
3. in cases where the absorption of the fluid portion has at length
permitted the roughened surfaces to come in contact: for it is
obvious that the interposition of any considerable quantity of fluid,
by separating the surfaces, would suspend the phenomena, in
proof of this,' I have notes of several cases in which, so long as a
copious serous effusion was indicated bydulness on percussion and
the other signs of hydropericardium, (see Hydropericardium.) the
attrition murmur and tremour did not exist; but they commenced
so soon as a diminution of the dulness, &c. denoted that the fluid
had been sufficiently, though not wholly absorbed.1
The murmur is almost always double, accompanying the two
sounds of the heart, in correspondence with the movements of the
organ backwards and forwards within the pericardium. I have,
however, occasionally found it stronger with the first sound, and
once or twice I have heard it accompany that sound exclusively.
This might be anticipated, in consequence of the superior force of
the systolic movement.
The murmur presents very diversified characters, which appear
to me to depend on the degree of firmness and roughness of the
lymph, the quantity of fluid with which it is mixed, and the greater
or less violence of the heart's movements. These diversities, there-
fore, do not diminish the value of the sign, but they require to be
severally described, lest the auscultator, from ignorance of what he
has to anticipate, should wholly overlook the sign when he encoun-
ters one of its more uncommon varieties.
The murmur, then, has generally more or less of a rough cha-
racter, sometimes like the rasping of wood, or the grating of a
nutmeg; or sometimes like the rustling of silk, or even the crackling
of parchment (Bouillaud). Occasionally it has a softer character,
approaching to ordinary bellows-murmur. Very rarely, it resembles
the creaking of a new shoe-sole. I have also heard a lower croak-
ing tone, like the tearing of linen cloth ; and I have likewise heard
a continuous hollow rumble, not noticed by authors, and which I
ascribe to the agitation of as large a quantity of fluid as is com-
patible with the production of a murmur ; for in one case, in which
the fluid originally caused dulness as high as the second rib, the
rumble came on, with tremour, when the quantity of fluid became
moderate; it passed into a double attrition sound, with tremour,
when the fluid underwent further absorption, and both phenomena
ceased when complete cessation of dulness and other signs indi-
cated adhesion of the pericardium, which I ascertained to have
taken place by post-mortem examination a year and a half after-
wards.2
[' The friction sounds of pericarditis, when effusion is slight, are most
frequently first heard near the base of the heart. — P.]
2 Case of Robert Jones. The murmur and thrill were perceptible latest at
the base of the heart, and I found that this was the only part where adhesion
had not taken place. From this and other cases, I suspect that the last
spot from which fluid is absorbed, is the angle between the base of the heart
and the great vessels.
176 HOPE ON DISEASES OF THE HEART.
It may strike the reader as rather incredible that so many varie-
ties of rubbing murmur should be produced by a single affection;
but his doubts will cease on finding that he may closely imitate
nearly the whole, even the creaking sound, by rubbing a damp
finger, with various degrees of force, and in various positions,
against the back of his hand, while he listens with a stethoscope
applied to the palm. From experimenting in this simple way, and
from the cases which I have seen or read of, I think it probable,
1, that the rough sounds of rasping, grating, &c, are referable to
firm and rugged lymph, the sound being louder in proportion as
the lymph is rougher and the action of the heart stronger ; 2, that
the rustling and crackling sound are referable to soft and wet
lymph ; for I have often heard the same from friction of lymph on
the pleura immediately after absorption of the fluid ; 3, that the
softer rubbing sound like bellows-murmur is due to soft, dryish
lymph ; for I have often heard the same from friction of lymph on
the pleura long after the fluid had been absorbed : 4, that the
creaking and croaking sounds are owing to very dry, tough lymph
or granulations; for such was the state of the parts in the two cases
recorded by M. Bouillaud (Traite, Pericarditis, cases I and 4), and,
apparently, in two cases by Dr. Stokes (cases 3 and 4, Dublin Jour-
nal, vol. iv) : further, the creaking sound may be imitated by rub-
bing together the fingers made sticky by resin, or even by dampness
alone. This experiment leads me to think that deficient lubricity
of the pericardium, from defective secretion in the earliest stage of
inflammation, may possibly be one of the causes of the creaking
sound, independent of lymph. This was M. Collin's explanation,
and it has generally been rejected because it did not explain all
cases ; but I suspect that it will be found correct as far as it goes.
5. That the continuous rumble is owing, as already stated, to the
churning of a little fluid.
My main object in offering these explanations is, to render the
murmurs intelligible by describing how they may be imitated. To
the explanations in the abstract, whether correct or not, I attach
little importance ; since, provided it can be ascertained that there
is an attrition murmur, it matters little which of the above charac-
ters it presents, and what is the particular state of parts producing
it. The best proof of this is, that, a murmur may pass through
several or most of the above characters in the progress of a single
case. The transitions may be remarkably rapid ; as, for instance,
when an abstraction of blood, by diminishing the force of the heart's
action, and consequently the violence of the attrition, suddenly
converts a loud rasping or grating sound, with distinct vibratory
tremour, into a soft bellows-murmur without tremour (Stokes).
Different kinds of murmur may even exist over different parts of
the same heart. These transitions, &c. even augment the value of
attrition murmurs as signs, because they are not observed in valvu-
lar murmurs.
When the effusion of lymph is limited to a particular spot, the
ANATOMICAL CHARACTERS OF PERICARDITIS. 177
murmur exists at the corresponding part alone. Thus, in some
cases, Dr. Stokes found the signs at the apex only; in others,
merely on one side; and in one case he was able to trace the
extension of the disease over the entire surface of the heart by the
corresponding advances of the murmur.
The same gentleman has observed, as a corollary to the pre-
ceding paragraph, that the extent to which the sounds of attrition
are propagated, is in general very limited. In by far the greater
number of his cases, they were not audible beyond the actual
region of the heart, and he "has often observed that, on moving
the stethoscope little more than an inch from a situation where the
sounds were loud, they totally ceased, although the contractions
(sounds) of the heart continued distinctly audible." I suspect that
this limitation of the murmurs results from nothing more than their
weakness, aided, perhaps, in some cases, by their being generated
on the posterior surface of the heart; for when a murmur, gene-
rated on the anterior surface, is loud, I see no reason why it should
not be extensively propagated. Accordingly, in Dr. Watson's case
(Med. Gaz. April 11, 1835, p. 62), the murmur, which " represented
very exactly the upward and downward action of a saw on rough
wood, was by far the loudest sound of the kind that he ever heard.
It was distinct over the whole of the chest, both before and behind,
only somewhat fainter as the distance from the heart became
greater: with your ear upon either scapula, you might have sup-
posed that you were listening to the deep buzzing vibrations of the
larger string of a bass viol." This was occasioned by the pericar-
dium being covered, except upon the posterior surface of the left
ventricle, "with a thin coat oi firm, gray lymph, quite rough with
minute papillae, projecting from almost every point of its surface, of
an almost horny consistence, harsh and resisting to the touch, &c."
Bouillaud also mentions (Case 1. of Pericarditis) a creaking sound
which could be heard an inch from the precordial region.
[The friction sounds in well marked pericarditis are almost always double,
and frequently may be even triple or more. For. when effused lymph is
attached to the pericardial surfaces, each division of the heart during its
systole, moves so as to cause a friction upon the opposed surface of the peri-
cardial sac; and during its diastole a similar rubbing may exist, although in
an opposite direction. Now, since the auricular movements are independent
of those of the ventricles, their movements are also double ; so that if friction
exist both upon the auricular and ventricular surfaces, the attrition sounds
will be quadruple, or, double with the auricles, and double with the ventri-
cles. The attrition sounds are designated by many of the English writers
as " the to and fro sounds" in allusion to the movements of the heart.
The natural sounds of the heart may be completely marked by those of
friction of the precordial surfaces; in such cases, the proper cardiac sounds
may be heard near the upper portion of the sternum. The friction sound
generally ceases in a few days; for the lymph is absorbed, or it is converted
into a false membrane which connects the heart with the pericardium.
When mucous, or crepitant ronchi exist over the precordial space, the
crackling sound often bears some resemblance to that of friction, rendering
it doubtful, whether the morbid sound occurs during respiration, or whether
it is caused by attrition. This doubt may be resolved, by requesting the
9— g 12 hope
178 HOPE ON DISEASES OF THE HEART.
patient to hold his breath for a short time, and examining the prsecordium
at that moment: if it be found that the sound has then ceased, it has
evidently been generated in the lungs, but if it continues, it is friction
sound.— P.]
Adhesion of the pericardium may be inferred from three circum-
stances ; first, cessation of a distinct attrition murmur ; second, no
increase of dulness on percussion, whence the cessation cannot be
attributable to fluid in the pericardium ; third, strong jogging, and
sometimes double-jogging action of the heart, even though fever
has subsided — a phenomena referable to the organ being bound to
the spine by the adhesion (See Adhesion of the Pericardium).
Resolution may be inferred if an attrition murmur ceases with-
out leaving increased dulness on percussion, or inordinate jogging
action, while all the other signs indicate resolution.
It may be inferred that neither adhesion nor resolution has
taken place, if an attrition murmur continue up to the time of
death.
I postpone explaining the diagnosis of murmurs of attrition from
valvular murmurs, till 1 have noticed the latter, to which we next
proceed.1
1 When the first edition of this work was published, the class of murmurs
from attrition of the pericardium had not been discovered, with the excep-
tion of the "creaking of new leather," (craquement de cuir neuf,) by M.
Collin, in 1S24. I was criticised by Dr. Stokes in an Irish review for not
even mentioning this sign. I must frankly confess that I doubted its exist-
ence ; for I had searched for it in vain, and had never met with any one,
either in this country or in the Parisian hospitals, who had heard it. Nor
will my incredulity now appear surprising; for M. Bouillaud states in 1835
that neither he nor Andial had heard it in a pure form more than once
(Traite, i. 198): Laennec, Louis, Rostan, Bertin, Latham, Elliotson, all
writers on pericarditis, had not heard it; Dr. Stokes in 1834 heard it twice,
and Dr. Watson in 1835 heard it twice.
The history of the discovery of the various murmurs of endo-pericarditis
is as follows. After the discovery of " creaking of new leather" by Collin,
in 1824, Dr. Latham, in 1826, discovered a bellows-murmur with the first
sound, as a sign of rheumatic pericarditis. He communicated this to me in
the same year; and I found, and published in the first edit., in 1831, that
the murmur accompanied not only rheumatic, but any kind of pericarditis,
that it sometimes attended the second as well as the first sound, that it was
referable, not to the pericardium, but to co-existent endocarditis, and that it
was the earliest and best sign of inflammation of the heart. Dr. Elliotson
had, unknown to me, published in the previous year, that the murmur was
referable to endocarditis. I can now distinctly recollect various cases in
which I noticed that the murmurs were, "croaking," " anomalous," "extra-
ordinary;" and I entertain no doubt that these were attrition murmurs: I
failed to discriminate them, because, during the last ten years, not having
had a fatal case of acute pericarditis, I have not had the opportunity of post-
mortem verification. Had Collin given a happier name than crie de cuir
neuf to attrition murmurs, I have no doubt that they would much sooner
have been recognised. Though the honour of giving the first clue to this
class of murmurs belongs to Collin, and though Broussais, as will presently
be shown, noticed the sound like rubbing of parchment, yet the merit of
satisfactorily unraveling the whole subject is, in my opinion, to be awarded
to Dr. Stokes (Dubl. Jour. vol. ii. Sept. 1833). Apparently without being
ANATOMICAL CHARACTERS OF PERICARDITIS. 179
["I have sought in vain for the 'jogging or tumbling motion,' which
has been stated to be characteristic of an adherent heart. Such motion
results from irregular action, often exists without any adhesions, and in
some measure depends on the motion of the lung differently affecting suc-
cessive irregular pulsations. But it often happens in case of close adhesions,
that, prior to their formation, the pericardial sac has adhered in its distended
state to the walls of the chest at the left of the sternum, so that when the
heart also adheres to the sac, it constantly pulsates in close contact with
these walls. This combination of circumstances gives us very appreciable
signs. In the first place, the motions of the heart may be seen and felt
much more plainly and widely than usual, drawing in the intercostal spaces
at each systole. Then these motions, instead of being, as usual, intercepted
aware of the researches of Dr. Stokes, Dr. Watson also published, in the
Med. Gaz. April 11, 1S35, two cases of endo-pericarditis, in which he
describes the to-and-fro sound of attrition, and perfectly distinguishes it
from the co-existent valvular sound. M. Bouillaud does not appear to claim
originality respecting the attrition sounds, but states that he had observed
bruit de soufflet in pericarditis at a period when he wTas completely igno-
rant of the labours of Drs. Latham, Hope, and Stokes (Traite, i. 457).
I shall now subjoin quotations from Collin and Broussais, to show that
their observations, though so long rejected, were correct so far as they went.
Collin says, "The sound analagous to the creaking of new leather has only
once fallen under my observation: it was in a man who died of chronic
pericarditis. The sound continued during the first six days of the disease,
and disappeared so soon as the local symptoms announced a rather abundant
liquid effusion into the pericardium." He then relates that M. Dervilliers,
elee interne at the hospital St. Antoine, met with the sound twice. In one
case, the patient left the hospital, and the result was unknown: in the
other, "he made a post-mortem examination of a man who had presented
the sound during the whole period of his stay in the hospital. He found a
chronic pericarditis, which had occasioned the formation of thick false mem-
branes and numerous vegetations on the pericardium and heart. Between
the surface of the organ and its envelope there were only a small number of
adhesions, and the cavity did not contain a drop of serum." Collin here
remarks, "Perhaps this sound will prove a constant symptom of pericar-
ditis before the existence of effusion into the pericardium — a symptom,
which will be very transitory in the cases in which the disease terminates
in a few days, and more prolonged when it is chronic (p. 64)." He adds
(p. 116) " I shall explain the phenomenon by the friction of the two layers
of the dried serous membrane. This kind of dryness seems to be the first
effect of inflammation on the membranous tissues." (On the various modes
of exploration of the chest. By V. Collin. Paris, 1S24.)
Dr. Stokes says that Broussais is the only author that he can find, subse-
quent to Collin, who brings his own experience to bear on the subject.
Speaking of the symptoms of inflammation of the heart, he says, " There is
a phenomenon worthy of attention, to which enough has not perhaps been
given: it is the sound of parchment, which is very perceptible by means of
the stethoscope. On exploring with this instrument in commencing peri-
carditis, the sensation is experienced which would be given by two dry
bodies, as parchment, rubbing against each other; and this sign, when con-
joined with pain and distress (angoisse) can leave no doubt as to the exist-
ence of the inflammation" (Commentary on the Propositions of Pathology,
1829, vol. i. p. 393).
The number of individuals who, though unacquainted with each other's
labours, have contributed to the discovery of the murmurs of endo-pericaiditis,
must afford convincing evidence, to the incredulous, of the reality of these
murmurs.
12*
180 HOPE ON DISEASES OF THE HEART.
by the expansion of the lung in a full inspiration, are always close to the
"walls of the chest; for these walls, instead of, as usual, rising from the
heart upwards and outwards at each inspiration, carry the heart with them
in all their movements. Under these circumstances, therefore, there will be,
proportioned to the adhesion and the size of the heart, a space in which the
pulsations' are always felt, and the sound on percussion is always dull in
every stage of respiration and in every posture of the body. When the heart
is thus generally adherent to the pericardium, and this to the diaphragm and
walls of the chest, the enlargement of the organ which very commonly
ensues, cannot readily take place as usual, downwards and to the left, but it
proceeds upwards and outwards, carrying with it the walls of the chest, to
which it gives a remarkable projection about the ends and cartilages of the
middle ribs. I have seen this accompanied by a retraction or hollow at the
epigastrium. In other cases again, from the adhesions being more partial,
the enlargement may take place laterally, and bring the pulsating apex of
the heart far to the left side. Various other changes of position may arise
from other circumstances, especially when the pericarditis has been con-
joined with pleurisy." — (C. J. B. Williams* Lectures.)—'?.']
The second class of murmurs indicating pericarditis are indirect
signs, and afford merely presumptive evidence. They proceed
from valvular affections occasioned by co-existent inflammation of
the lining membrane of the heart. This causes the valves to
become red, swollen, thickened, and sometimes studded at their
free margins with granulations of lymph, denominated vegetations.
These morbid conditions contract the valves, so as to generate a
murmur when the blood passes through them in its natural direc-
tion : further, the contraction frequently renders them incapable of
closing their respective orifices, whence a second murmur is pro-
duced by the blood regurgitating, or flowing retrograde through
them. Thus the murmur may be either single or double, that is,
may accompany either one or both sounds. The murmur with the
first sound may proceed either from contraction of the aortic valves,
or regurgitation through the mitral; or from the corresponding
affections on the right side of the heart — which, however, I have
found very rare. The murmur with the second sound I have
almost always found to proceed from aortic regurgitation. For
the mode of ascertaining which is the particular valve affected, the
reader is referred to Disease of the Valves, Physical Signs: also,
to p. 90.
I think that these valvular murmurs from endocarditis are enti-
tled to the rank of presumptive signs of pericarditis, because I have
found them to exist in the immense majority of cases of the latter
affection. In the first edition of this work, (I went so far as to say
that " I had never found them absent when the heart presented an
increased, jerking impulse" (p. 110) ; but I now think that I some-
times inadvertently included amongst them attrition murmurs, with
which I was not then acquainted. Subsequent writers, however,
have confirmed my observation above quoted almost in its full
extent. Thus Dr. Watson says, " If I cannot affirm that the inter-
nal membrane is always affected, I believe that it very seldom
(perhaps never) escapes. My reasons for thinking so, are, first, the
ANATOMICAL CHARACTERS OF PERICARDITIS. 181
deep blowing sound (which, in these cases, I hold to denote an
affection of the inner membrane) is rarely (perhaps never) absent."
(Med. Gaz. April 11, 1835, p. 64). M. Bouillaud speaks almost as
strongly. Now if endocarditis so frequently attends pericarditis,
the valvular murmurs, which are direct signs of the former, must
be valuable indirect or presumptive signs of the latter: and 1 am
desirous of strongly drawing the reader's attention to their value,
because they have, of late years, been too much depreciated in
consequence of the absorbing attention which has been paid to
attrition murmurs; whereas I feel as confident now as I expressed
myself in the first edition of this work, that the valvular murmur
is the physical sign which most frequently yields the first intima-
tion of inflammation of the heart. Dr. Watson more recently ex-
presses a similar opinion : '-'This to-and-fro (attrition) sound," says
he, " is not the sound which is most commonly heard in the outset
of these cases of rheumatic carditis : it is the deeper blowing sound
or whiz which we hear, and which excites all our anxiety to save
the patient from that mischief, the commencement of which it indi-
cates ; namely, alteration of the valvular parts of the heart." (Ibid.
p. 63.) The reason why the valvular murmur gives early intima-
tion of pericarditis more frequently than the attrition murmur, I
believe to be this: — pericarditis, in the majority of cases, is attended
with copious serous effusion almost from the first, which prevents
the development of the attrition murmur; whereas the same peri-
carditis is, in the immense majority of cases, attended with endo-
carditis, which almost necessarily produces a valvular murmur:
hence the latter murmur occurs id the majority, and the attrition
murmur in the minority of cases.1
1 M. Bouillaud has not done justice 10 my account of the valvular mur-
murs occurring in pericarditis. He says that I had only a "glimpse"
(entrevue) of the influence exercised by endocarditis in producing the bel-
lows-murmur, and he represents me to have stated "that the bellows-mur-
mur which takes place during the diastole, is the only one which should
cause us to suspect this complication, so common in pericarditis." How
totally he is mistaken will appear from the following passages in my first
edit. p. 110. "This sign (the bellows-murmur with the first sound) was
first noticed by Dr. Latham, who pointed it out to me at St. Bartholomew's
Hospital in 1S26. Since that time I have never found it absent when the
heart presented the increased, jerking impulse. Dr. Latham restricts his ob-
servation to rheumatic pericarditis: to myself the phenomenon has appeared
to exist equally in every form of the disease. Not the ventricular systole
only, but occasionally, though by no means always, its diastole likewise, is
attended with the bellows-murmur: and I have found this supersede, and,
as it were, annihilate the natural second sound more completely in pericar-
ditis, than, I think, in any other affection of the heart. Sometimes, in short,
it is a pure whizzing equally prolonged as, and almost continued into, the
first sound."
I offered two explanations of the murmur with the ventricular systole. I
thought it "probable" (a stronger term is not used) that it was mainly
referable to the morbidly abrupt contractions of the heart, &c, as occurred
in dogs repeatedly bled. This explanation proved to be incorrect. The
second explanation I did not offer as probable, but as certain: — "I believe
182
HOPE ON DISEASES OF THE HEART.
Diagnosis of Valvular from Attrition Murmurs. Some writers,
especially M. Bouillaud (torn. ii. p. 211), have experienced great
difficulty in discriminating these two classes of sounds. 1 cannot
say that, since I became acquainted with attrition murmurs, I have
participated in this difficulty — even when the two classes of sounds
existed simultaneously, and each was double. This is mainly from
attending to the rules which I have so often inculcated ; namely, of
listening to murmurs of the sigmoid valves two inches or more up
the aorta or pulmonary artery, where attrition murmurs are mostly
inaudible ; and of listening to murmurs of the auricular valves a
little above the apex of the heart, where they are sure to be the
loudest, whereas attrition murmurs may be louder at other parts of
the heart where they happen to be generated. Further, attrition
murmurs present the following distinctive peculiarities —
1. They are usually of a much rougher quality of sound than
the valvular, so that, when the two co-exist, the one may be heard
through the other.
2. When a murmur with the second sound is rough, as rasping,
creaking, croaking, &c, it is certainly from attrition ; as I have
never known a valvular murmur with the second sound to be
rough, the diastolic currents being too feeble to produce roughness
(See p. 107).
3. Attrition murmurs are almost always attended with vibratory
tremour ; whereas valvular murmurs rarely present this phenome-
non, and generally in a slighter degree.
4. Attrition murmurs are apt to undergo frequent and sudden
changes of character and of situation (Stokes,) which are very
pathognomic, because valvular murmurs change little in character,
and not at all in situation.
Signs and Diagnosis of Chronic Pericarditis.
General Signs. — When acute pericarditis runs on unsubdued
that it (the murmur with the ventricular systole) may, in some instances,
originate partly in another cause: namely, constriction of the arterial
orifices consequent on inflammation of the lining membrane. For, as this
membrane is more liable to inflammation where it constitutes the valves,
than elsewhere, it is consistent with analogy to suppose that, by its intu-
mescence and loss of elasticity, the orifices will undergo the constriction
alluded to." Surely I had here more than a "glimpse" of endocarditis, and
it was the murmur with the systole, and not with the diastole alone, as M.
Bouillaud states, that indicated it. Again, "The murmur accompanying
the second sound, I am inclined to attribute perhaps entirely to the same
constriction. This I infer, because I have not found it produced, in any
appreciable degree, by abrupt jerking action of the heart in reaction from
loss of blood, and in nervous palpitation ; and because, when I have noticed
it in pericarditis, I have invariably found it connected ivith a more or less
thickened state cf the valves. Should this be found true, the bellows-mur-
mur of the second sound renders the prognosis more gloomy; as it bespeaks
a more extensive inflammation, and the probability of-subsequenl valvular
disease." Again, I said at p. 115, "When there is inflammatory constric-
tion of the orifices, a murmur will attend both sounds."
ANATOMICAL CHARACTERS OF PERICARDITIS. 183
beyond ten days or a fortnight, the full limits of its ordinary dura-
tion, it becomes what is called chronic. The same name is given
to the disease when, from the first, it runs a slow, insidious course,
without marked or violent symptoms.
The general signs of chronic pericarditis are, in their nature,
much the same as those of acute, but they are less in degree. Thus,
the fever, instead of being of the smart, inflammatory kind, is more
that of hectic or marcor, because there is usually suppuration or
irritative emaciation; but there are occasionally active exacerba-
tions, when, perhaps, the inflammation becomes subacute. The
anxiety and restlessness, though sometimes great, are comparatively
supportable. The position is less constrained, and I have observed
that, when there is much fluid in the pericardium, the patient often
prefers the sitting posture with the body inclined forwards. The
circulation is less embarrassed, and the action of the heart, in the
absence of adhesion of the pericardium and hypertrophy, is usually
somewhat feeble, except during any temporary exacerbation of in-
flammatory action. It is sometimes not very irregular, intermittent,
and unequal, though the pericardium be full of fluid; which I
attribute to the elasticity of the membrane not being so far destroyed
by the inflammation as to prevent it from gradually undergoing
extension, and accommodating itself to its contents; whence com-
pression of the heart by the fluid is in some degree obviated. The
patient, I have thought, more frequently complains of a load and
fulness " something which he cannot get down," in the scrobiculus
cordis, in chronic, than in acute pericarditis. In a considerable
number of chronic cases, I have found oedema of the legs to occur:
once within a month, in others, later. Louis saw it in two cases of
less than six weeks duration. This is an important general sign, as
indicating an obstacle to the general circulation.
This inferior degree of violence in the symptoms renders chronic
pericarditis, especially if such from its commencement, more obscure
than acute. I have, in former years, when auscultation was little
known, seen it overlooked more than once. But these cases, when
I now revert to them, appear to me to have presented sufficiently
characteristic symptoms. The history affords great light. If the
patient, previously exempt from disease of the heart, has become
affected with its symptoms, attended by marcor and some degree of
fever, within a period seldom extending beyond a few months, and
which he often dates from a blow or fall on the breast, a rheumatic
fever, or an inflammation with pain in the precordial region,
chronic pericarditis may be strongly presumed; and if these symp-
toms coincide with the physical signs of fluid in the pericardium,
or with attrition murmurs indicating lymph, the existence of the
malady may be regarded as certain.
Physical Signs. — The impulse is, caeteris paribus, weaker than
in acute pericarditis without effusion, because, the inflammatory
irritation being less active, the movements of the organ are less
violent. If there be hypertrophy, which is apt to supervene after
184 HOPE ON DISEASES OF THE HEART.
the lapse of two or three months, the impulse will sustain a corre-
sponding augmentation of force ; and if there be adhesion of the
pericardium over any considerable extent, it will be more or less
jogging, as well as strong.
The sounds will vary according to circumstances. They may
be natural, provided there be neither dilatation, which augments
them, and shortens the first; nor attrition of lymph within the
pericardium, which creates an attrition murmur with one or both
sounds, and a vibratory tremour; nor inflammatory constriction of
the orifices, which may produce a bellows-murmur with one or
both sounds (see p. 180), and a jerking pulse if there be aortic
regurgitation (p. 174).
The signs of fluid in the pericardium are the same as in acute
pericarditis (p. 173) ; namely, the extensive dulness on percussion,
and the undulatory impulse.
SECTION III.— Causes of Pericarditis.
The most frequent causes are, blows, wounds, punctures,1 or
excessive pressure on the praeeordial region, inflammation pro-
pagated from the lungs or pleura, and,/ar above all, acute rheu-
matism. From this cause, children and young persons, that is,
those between the ages of eight and thirty-five, suffer much oftener
than others — a fact which I have ascertained almost numerically
on a vast number of cases. The remaining causes are, those of
inflammation in general; viz. cold, febrile excitement, &c. M.
Bouillaud assigns the same causes; for he says, "Of the exciting
causes, the most powerful, frequent, and consequently that which
it is the most important thoroughly to understand, is, incontestably,
a quick and sudden chill, following a great heat, with copious
perspiration, of the body, and more or less violent and fatiguing
exercises." (Traite, i. 169 and 171.) In the next sentence he re-
solves this cause mainly into rheumatism : for he says, " Hence,
we ought not to be supprised if pericarditis is so commonly the
companion, I do not say of pleurisy and peripneumony only, but
also of hyper-acute rheumatism of the joints. Who knows not, in
fact, that this latter inflammatory fluxion has 'precisely for its
principal cause, the vicissitudes which I have just specified ?"
He then intimates that Corvisart had some idea of the connection
between rheumatism and pericarditis; since that illustrious author
says, "I am disposed to regard as a frequent cause, amongst
others, of this adhesion (of the pericardium), rheumatic and gouty
affections." He employs the remainder of the chapter in attempt-
ing to show that the connection in question " had been almost en-
1 M. Desclaux has produced pericarditis and endocarditis by piercing the
pericardium and heart with needles. M. Renauldin relates a case of the
same in the human subject— an individual who had made several attempts
at suicide. (Bouillaud, Traite, i. p. 649, note.)
ANATOMICAL CHARACTERS OF PERICARDITIS. 185
tirely overlooked in the great majority of cases up to the present
time." He consequently inculcates it as a novel doctrine, and. to
corroborate his opinion, does me the honour of a quotation to show
that I was fully acquainted with it. I have not, however, the
slightest pretension to originality in this idea; since, at the time
when I wrote, there was not a better established doctrine in the
London schools. The history of the discovery was as follows.
It appears to have been first made by Dr. Pitcairn in 1788. This
physician being too modest to publish, Dr. Baillie did it for him in
the second edition of his il Morbid Anatomy, 1794." The connection
in question was noticed by Sir David Dundas in 1808 ; also by
Dr. Wells, and by Dr. Odier of Geneva. Since then, it has been
noticed by every modern writer on pericarditis in this country;
for instance, Drs. Latham, Abercrombie, Elliotson, Davis of Bath,
and myself. I deem it unnecessary to offer evidence in substantia-
tion of a doctrine which I consider to be established beyond the
possibility of contradiction ; but I may state as a striking fact,
because derived from a great number of observations, that acute
rheumatism had preceded, in about three fourths of the worst cases
of valvular disease and adhesion of the pericardium, which have
occurred amongst upwards often thousand hospital patients, whom
I have treated during the last four and a half years. The follow-
ing statement of M. Bouillaud is also striking and important :
"Such, according to my experience, is the frequency of pericarditis
in rheumatic individuals, that one might affirm, a priori, that, out
of twenty patients affected with universal acute rheumatism of the
joints, accompanied with smart fever, the half at least, would pre-
sent symptoms of pericarditis or of endocarditis, and often, of these
two inflammations united." (Traite, i. 472.) This statement would
appear incredible to non-auscultators, because they must almost
necessarily overlook those cases — especially of endocarditis, which
are scarcely revealed except by physical signs ; yet, according to
my own observation, the statement is not wide of the truth when
rheumatic affections are neglected or inefficiently treated.
. [The experience of American auscultators entirely accords with the views
of M. Bouillaud. The connection of peri- and endo-carditis with acute arti-
cular rheumatism is extremely frequent, occurring in at least one half the
cases. The complication is met with more frequently in the young than in
the aged patients. It should always be recollected in the treatment of acute
rheumatism, for if overlooked it lays the foundation of the various forms of
cardiac disease. Pericarditis and endo-carditis are generally associated,
but, of the two, the latter occurs more frequently than the former. — P.]
The extension of rheumatic inflammation to the heart or dura
mater, (of which latter, however, I have never seen a distinct in-
stance,) was formerly regarded as a metastasis, that is, a change
of seat — a total desertion of the external parts and a concentration
of the disease on the internal organ. But I have no hesitation in
expressing my unqualified conviction that this idea is erroneous —
an obsolete relict of antiquated ignorance ; for 1 have not only, in
186 HOPE ON DISEASES OF THE HEART.
cases innumerable, seen the heart attacked while the rheumatic ex-
isted in full intensity in the joints, but I have seen the heart attacked
before the joints, and I know that other practitioners have seen the
same. Dr. Charles of Putney lately (January 1828) favoured me
with one instance. Hence, I believe that what has been called
metastasis, is nothing more than an extension of the inflammation
to the internal fibrous tissues, namely, of the peri- and endo-cardium,
of the dura mater, sclerotica, &c, precisely as it extends or migrates
from the fibrous tissue of one joint to that of another, by what
Bichat lias happily denominated the " affinity of tissue."1
1 Reflecting on what has now been said above, relative to the frequency
of peri- and endo-carditis in acute rheumatism, and to the frequency of incu-
rable valvular and pericardiac disease as sequels of the peri- and endo-car-
ditis. are we not driven to exclaim, how important, how fearful a disease is
acute rheumatism ! — an affection till lately, — in short, till auscultation threw
light upon it, considered painful and troublesome, indeed, but harmless to
life! I have made brief notes of between two and three hundred cases, and
observed many more, with the view of ascertaining by comparison which
was the most successful mode of treatment. The results are published,
from a lecture by the writer, in the Med. Gaz. February 25th, 1837; but, con-
sidering the magnitude of the subject, it may not be irrelevant here to glance
at them.
The most successful treatment beyond comparison, was a modification of
that introduced fifty years ago by Dr. Hamilton of Lynn Regis, who, in ad-
dition to bleeding and purgatives, excited salivation by calomel and opium.
The modification to which I allude, and which merely consists in avoiding
salivation, I first saw employed by my colleague Dr. Chambers, in Si.
George's Hospital. Leaving the merit of the plan to him, I shall offer my
own experience of it in about two hundred cases of acute, and active chronic
rheumatism.
1. In acute rheumatism. After one full bleeding, or even two in robust
subjects, but without any bleeding in the feeble and delicate, I give, every
night, gr. vii of calomel with one and a half of opium, or gr. x of calomel
with gr. ij of opium, according to the age and the severity of the symptoms.
This is followed every morning by inf. sennse c. §iss, magnesias sulph. jjij,
and mannse gj, which should act at least four or five times. In addition,
(though tins is not a part of Dr. Chambers' plan,) I generally give the fol-
lowing draught thrice a day, as it has appeared to me to expedite the cure
— partly, perhaps, by the additional opiate, and partly by the sedative effect
of the colchicum. £ vini colchici, m xv ad xx ; pulv. ipecac, comp. gr. r;
mist, salin. gx ; syrupi, gj TT[ft. haustus.
When the pain and swelling are greatly abated, if not almost gone,
(which often happens within two days, and almost always within four,) I
omit the calomel, or, if the gums become in the slightest degree tender, I
omit it even earlier. The opium, I continue, to the extent of gr j or iss at
bedtime, and in severe cases I add a grain at noon, — for, without an anodyne,
the pains are apt to recur. I also continue the colchicum draughts and the
senna draught.
No local treatment is necessary beyond warm or cold applications, ac-
cording as the patient finds them agreeable.
If the patient is not well in a week, I consider it a case of exception ; and
the exceptions are generally in those who are subject to rheumatism, and
who, therefore, usually have it in a more obstinate, chronic form. The ad-
vantages of this plan are, 1. The patient is generally well, sound, and fit
for work in a week or ten days after the pains have ceased. 2. The gums
are rarely affected— especially if it be previously ascertained that the patient
ANATOMICAL CHARACTERS OP PERICARDITIS. 187
SECTION IV. — Progress and Duration, Terminations and Prognosis of Pericarditis.
Progress of Pericarditis. The progress and duration of this,
as of most other inflammations, varies according to circumstances.
If intense and extensive, and especially if complicated with severe
endocarditis or pleuritis, it may be fatal within thirty or forty
hours. Andral relates a case of rheumatic pericarditis, without
other complication, which terminated in twenty-seven hours. (Clin.
Med. iii. p. 416. 1826.)
I have not treated a case during the last ten years, on the plan
alluded to in the last note and presently to be fully described,
which did not terminate favourably in a week or ten days, and
often much less. There may, however, be exceptions, and I
ascribe it to good fortune that they have not yet occurred to myself.
has not a peculiar susceptibility of the action of mercury. 3. It is rare to
see inflammation of the heart supervene, if the treatment is early com-
menced: I think that about one case in twelve would be the maximum in
my practice. 4. If the slightest symptoms of pericarditis or endocarditis do
supervene, a few additional doses of calomel and opium, (as gr. v of calomel
with gr. j of opium every four or six hours,) will generally affect the con-
stitution in twenty or thirty hours, which, with two or three cuppings or
leechings on the precordial region, almost always places the patient in a
state of safety. I have never lost a patient by rheumatic inflammation of
the heart since I have employed this plan, and I have been told by other
hospital physicians that they have been scarcely less successful.
2. Active chronic rheumatism. Here calomel and opium may be given
in smaller doses, as gr. v of calomel and gr. j of opium, every night; but
they require to be continued for a longer time, as five or six nights. Care
should, however, be taken to stop short of ptyalism, especially in the scro-
fulous. The oiher particulars of the treatment are the same as in the acute
form. Local treatment, however, is more beneficial than in the latter:
namely, the bleedings, if necessary, may be local instead of general, and
blisters, liniments, plasters, &c. may ultimately be employed if a joint con-
tinues obstinately affected.
I cannot doubt that the opium contributes importantly to the cure — per-
haps by allaying pain, and thus diminishing the irritative fever dependent
on it: or, possibly, by modifying in some unknown way the vital constitu-
tion of the blood. However this be, I have assured myself of the fact that
opiates and purging alone, will cure many cases of acute rheumatism re-
markably well. Others have used different narcotics with similar success.
My friend, Dr. Lombard of Geneva, states that he has had remarkable suc-
cess with the spirituous extract of aconite, in doses of gr. half, gradually
increased to gr. ij or even iij, every three hours. I have also heard that 9j
of conium daily, in divided doses, has produced good results.
M. Bouillaud has lately extolled, and introduced to his countrymen, ap-
parently as a novelty, the plan of copious and frequent bleeding at short
intervals for acute rheumatism. This plan, which is as old as Sydenham,
and which I saw carried to its very utmost limits, in Scotland, nearly twenty
years ago, is not to be compared in efficacy with the plan above described,
either as a prompt means of curing rheumatism, or an effectual mode of pre-
venting inflammation of the heart ; while it ha»the disadvantage of exceed-
ingly reducing the strength, and rendering convalescence very protracted.
I readily admit, however, that I have seen many cases promptly and effec-
tually cured by this plan.
188 HOPE ON DISEASES OP THE HEART.
Chronic pericarditis, once established, may run on several weeks,
or, if neglected, several months. I have notes of three or four such
cases.
Terminations of Pericarditis. Resolution is the most common.
The effused fluid and lymph are absorbed, but a little lymph fre-
quently remains, eventually constituting white spots of cellular tis-
sue, and sometimes forming the groundwork of cartilaginous and
osseous transformations. Authors also mention granulations and
vegetations, but I do not happen to have met with them. All these
depositions are sometimes rough, and they may then create an
attrition-sound : but authors seem to be agreed that, with the ex-
ception of extensive osseous or cartilaginous depositions, they are
not incompatible with perfect health. I have not had opportunities
of forming a confident opinion.
Adhesion of the pericardium is a less favourable termination.
The adhesions are sometimes partial, and, if not pervading a con-
siderable surface, they may become long and loose by extension, —
in which case they offer little or no impediment to the action of
the heart, and are consistent with the enjoyment of perfect health.
In other cases, they are universal, and they then, according to my
experience, offer an important, and in most instances an ultimately
fatal impediment to the action of the heart. This subject will be
fully noticed in the section on Adhesion of the Pericardium.
Chronic pericarditis is an occasional termination of acute, if the
latter be neglected or inefficiently treated, and especially if this
occur in a scrofulous or otherwise unhealthy constitution.
Valvular disease is a frequent termination of the endocarditis
accompanying pericarditis. It may be ascertained to exist by one
of the valvular murmurs described at p. 180, and by palpitation on
exertion, continuing after the fever and other inflammatory symp-
toms have subsided. If there happen to be aortic regurgitation,
the pulse will be eminently jerking, and this must not be con-
founded with the hard or sharp pulse, and lead the practitioner
into the gross error of supposing that it results from the persistence
of fever or inflammation.
Prognosis of Pericarditis. Before the diagnosis of pericarditis
was redeemed from deep obscurity by the light of auscultation ;
and, it may safely be added, before the use of mercury was under-
stood in the treatment of acute inflammation in general, pericarditis
was one of the most dangerous and destructive diseases in the
nosology. The acute and chronic forms were supposed by Corvi-
sart to be necessarily fatal, what he denominates the sub-acute form
alone affording a hope of recovery. This statement, however, must
now be admitted with limitation, since it is certain that Corvisart
and his cotemporaries must necessarily have overlooked many of
the slighter cases, which underwent resolution.
At the present period, I should venture to'say that, when the
treatment has not commenced at too late a period, the prognosis
of acute pericarditis with respect to life is decidedly favourable.
ANATOMICAL CHARACTERS OF PERICARDITIS. 189
Even M. Bouillaud, who does not employ mercury, and who, as
already stated, has introduced to his countrymen the system of free
bleeding as a supposed novelty, says, " What I can affirm for my
own part, is, that I have cured the greater number of cases of peri-
carditis that I have met with for some years ; and the truly extra-
ordinary success which I obtain every day from blood-letting
carried to a greater extent than is commonly done, in acute inflam-
mations in general, affords me a well-founded hope that the majority
of cases of pericarditis to which this method is wel.l applied, will
not resist it. The most rebellious, — the most destructive, will be
those complicated with intense endocarditis or very violent "pleurisy
or pleuro-peripneumony." (Traite, i. p. 476.)
The plan of M. Bouillaud, in all its details, has been universally
in vogue in this country, (where dread of the lancet has seldom
been a national sin — though I would not say so much for the con-
verse proposition,) during a period extending far beyond my recol-
lection; nor has its success, according to my observation, been less
than he represents — namely, a restoration of " the greater num-
ber? ' But this amount of success I consider to be very unsatis-
factory^ and I wish to express myself strongly on this point, in
order to draw attention to the use of mercury as an adjunct to the
antiphlogistic treatment. It has already been stated that I have not
lost a case of acute pericarditis during the last ten years, though
my opportunities as physician, successively, to two of the largest
hospitals in London, have not been limited. I have understood
that Dr. Latham, physician to St. Bartholomew's, did not lose a
case for a nearly similar period, till last year, when he lost two;
and Dr. Watson, physician to the Middlesex Hospital, informed me
that he also had lost only two or three in the same time. Hence
it appears that the mortality ought to be far less than that stated by
M. Bouillaud. I cannot numerically estimate the exact proportion,
but I should think that one fatal case in a dozen would be the out-
side. I do not mean, however, that adhesion of the pericardium,
or ultimate valvular disease from concomitant endocarditis, would
be prevented in the whole number of cases specified. In fact, the
valvular affection is exceedingly difficult to obviate: some say that
they seldom succeed: I have certainly been more fortunate, and
this I ascribe to my practice of pursuing an equally vigorous treat-
ment for it, as for the worst cases of pericarditis, and continuing
the mercurial and counter-irritant part of the plan for a much
longer period, as will hereafter be explained.
With respect to the prognosis when valvular disease is esta-
blished, it is more or less unfavourable according to the situation
and extent of the affection; but as the particular consideration of
this is long, the reader is referred for it to the chapter on valvular
disease.
1 In another part (torn. i. p. 480) he says, " Almost all the cases of peri-
carditis with which I have met." I am at a loss what to understand from
these discrepant statements.
190 HOPE ON DISEASES OF THE HEART.
The ultimate prognosis is unfavourable, as already intimated,
when adhesion of the pericardium has taken place ; and still more
so when, from bad diagnosis or inefficient treatment, pericarditis
with much effusion has become chronic.
In reference, therefore, to these three last terminations, and to the
fact that their prevention, or, in other words, the possibility of effect-
ing a complete cure, is limited to a very brief period and supposes
a high degree of diagnostic and practical skill in the practitioner,
endopericarditis must still be regarded as one of the most formida-
ble diseases incident to the human race and worthy of the deepest
study of the physician.
[Simple acute pericarditis, attacking for the first time a heart previously
sound, rarely proves fatal, provided the existence of the affection has been
ascertained at its commencement and judiciously treated. It should not be
regarded as the very fearful disease that it was formerly considered. It
was then known chiefly in those instances, where it was immediately fatal,
or where it was complicated with serious organic disease ; but these cases
offer in reality but a small proportion to the whole number that exist. It
has been shown that the affection is frequently latent, and we often have
evidence in post-mortem examinations of its former existence which had
been unsuspected, and where recovery had taken place. Louis, from exami-
nation of the bodies of those who had died of other diseases, finds traces of
former pericarditis of so frequent occurrence, that he considers that the dis-
ease does not prove fatal in more than one sixth of all the cases where it
occurs. This may be regarded as being under rather than above the truth,
for frequently the disease may have existed and all traces of it be obliterated.
Of its complications, endo-carditis is the most frequent, and where it is of
rheumatic origin, it is rarely absent, and is recognised by the bellows-mur-
mur and other signs which will be subsequently mentioned. Pleurisy and
pneumonia exist in the greater number of instances, and in childhood it is
frequently associated with scarlatina and the eruptive diseases. — P.]
SECTION V.— Treatment of Pericarditis.
Treatment of Acute Pericarditis? — The antiphlogistic treat-
ment, in as energetic a form as circumstance will allow, should be
employed with the utmost promptitude. The loss of a few hours at
first, may be irretrievable, and hence hesitation and indecision may
seal the fate of the patient. If the attack is recent and the patient's
strength will admit, blood should, in the first place, be drawn freely
and by a large incision, from the arm of the patient in the erect
position, so as to bring him to the verge of syncope. From five
and twenty to forty leeches, according to the strength, should then
be applied to the precordial region so soon as the faintness from
the venesection disappears and reaction commences, — which gene-
rally happens in the course of from ten minutes to an hour or two.
Unless the pain be completely subdued by these measures, the
1 Laennec did not even mention the treatment. MM. Bertin and Bouil-
Iaud, in 1824, recommend, in general terms, general and local bleeding,
rigorous abstinence and complete repose. Also counter-irritants for the
chronic form. •
ANATOMICAL CHARACTERS OF PERICARDITIS. 191
leeching, and in some cases the general bleeding also, may be re-
peated two, three or more times, according to the strength, at inter-
vals of from eight to twelve hours ; or, what is a better rule, so
soon as the pulse and action of the heart denote a recommencement
of reaction.
It is not, however, in every case, that so active a treatment is
required. I have seen a single prompt and abundant application
of leeches or a cupping at once subdue every formidable symptom.
When the patient, either from age, a feeble constitution, or the ad-
vanced state of the malady, cannot bear extensive depletion, local
bleeding is, according to my observation, decidedly preferable to
general : but it should be practised effectually, — by cupping to
twenty ounces or more, or by the application of from twenty-five
to thirty or forty leeches. When, from depletion having already
been carried to a great extent, or from the advanced stage of the
disease, it is not safe to draw much more blood, yet it appears ex-
pedient, from the persistence of pain, &c. to draw some, I have
generally found that a smaller quantity drawn by cupping produced
more effect than a larger by leeching. The cause of this probably
is, that, by cupping, it is drawn more expeditiously.
I may finally remark that, though blood ought to be drawn with
all the vigour that I have described when the usual indications for
its emission exist; yet, in cases where mercury is employed, as pre-
sently to be described, those indications so soon cease, from the
controlling power of this remedy, that the total quantity of blood
lost will rarely be considerable.
While the bleeding is in progress other means should not be
neglected. The intestinal canal, if at all confined, should imme-
diately be evacuated by a purgative enema. Three drachms of
senna leaves and an ounce of sulphate of soda infused in a pint of
boiling water, and strained, answers the purpose. If infusion of
senna is not at hand, a scruple of comp. extr. of colocynth may be
substituted. At the same time, five grains of calomel with five or
ten of comp. extr. of colocynth, and two or three of extr. of hyoscy-
amus, should be given, and, in two hours, be followed by a senna
draught.
The strength of the remedies employed must in each case be
apportioned in the vigour of the patient's constitution, but the
object is the same in all — expeditiously to prostrate the action of
the heart, and for a time to keep it prostrate by preventing the re-
establishment of reaction. If this object can be accomplished for
the first twenty, thirty, or forty hours, the disease frequently does
not rally, but remains perfectly under the control of remedies. I
feel satisfied that a degree of activity in the first instance, which to
some may appear excessive, is an ultimate source of economy to
the strength of the patient ; for the disease is subdued at once,
and the protracted continuance of depletory measures, the most
exhausting to the constitution, is rendered unnecessary.
In addition to the above measures, dilutent, cooling drinks, as
192 HOPE ON DISEASES OP THE HEART.
four scruples of supertartrate, or two of nitrate of potass in a quart
of water and flavoured at pleasure, should be allowed in unlimited
quantity, in order by diluting the blood to render it less stimulant
to the heart. Nauseating doses of tartrate of antimony, as one
sixth to one eighth of a grain, every two hours, may be employed
with advantage. The diet should consist wholly of the weakest
slops, as barley-water, gruel, weak tea, arrow-root, &c.
But the antiphlogistic treatment alone is not to be relied upon :
rarely does it, in a severe case, effect a complete cure. The prac-
titioner sees all his resources gradually exhausted, while the disease
proceeds with an even, uncontrolled tenor, to its fatal termination.
Sometimes, indeed, all the other symptoms disappear, but the action
of the heart remains stronger than natural : at other times the heart
even regains its healthy action and the cure appears complete;
ye^ in both these cases, the palpitation, accompanied with symp-
toms of organic disease of the heart, recurs when the patient
resumes his accustomed occupations. The reason of this is very
intelligible. Unless the effused lymph, as well as the serum, be
absorbed, it causes an adhesion of the pericardium, and thus con-
stitutes a destructive disease; or, if the pericarditis was complicated
with endocarditis, an irreparable valvular lesion is its sequel. Now
antiphlogistic measures can neither prevent the effusion of lymph,
nor with any degree of certainty cause its absorption. Mercury
can do this,— as is visibly displayed in iritis, and as has been
proved in this country by an overwhelming amount of irrefragable
evidence, ever since the mineral was introduced as a remedy for
acute inflammations by Dr. Hamilton of Lynn Regis, in 1783.
Mercury, therefore, is the sheet-anchor of the practitioner. Dr.
Latham is of opinion that its success is restricted to the condition
of its producing salivation, and producing it rapidly. Though,
from many observations, I am satisfied that there is an advantage
in promptly producing a decided effect; and though, therefore, I
always aim at this by administering full and frequent doses at first ;
yet I do not think that success is restricted to the condition of sali-
vation, or even of a sensible effect on the gums being produced;
for I have frequently seen cases in which cures, not falsified after
many months, were effected, though salivation was not produced.
The mineral, however, was freely administered, and probably pro-
duced its specific effect though not in an apparent manner. If,
therefore, there be a distinct and decided suspension of the symp-
toms before the gums are touched, I do not hesitate to diminish or
even omit the mercury, as I am never willing to push the remedy
beyond what is barely sufficient to subdue the disease. From five
to eight grains of calomel, or, as less irritating for delicate bowels,
from ten to fifteen of blue pill, prevented from purging by a grain
or a grain and a half of opium, three times a day, commencing after
the first bleeding and a purgative, generally produce the effect with
sufficient expedition. When greater promptitude is required, ten
grains of calomel with two of opium may be given at the first dose,
ANATOMICAL CHARACTERS OF PERICARDITIS. 193
and three grains with half a grain of opium, every three hours
afterwards. Inunction maybe superadded, or, if even the milder
preparations, (pil. hydrarg. or hydrarg. cum creta,) taken internally,
irritate or purge, it may be partially or wholly substituted. Any
quantity between £ij and 3J of the ung. hydrarg. fort, may be
rubbed into, or smeared on the arm-pits and groins, night and
morning; but, to avoid unnecessary salivation, the latter quantity
should not be used more than three or four times, unless it be
wholly substituted for the internal preparations. A manifest abate-
ment of the symptoms generally takes place immediately on the
effect of the remedy becoming apparent in the mouth — especially if
a decided soreness is established within the first thirty or forty
hours. A tender state of the gums (for more is scarcely neces-
sary) should be maintained for a week or ten days or even longer,
unless the symptoms completely yield before the expiration of this
period.
Should pain continue in the advanced stages of the malady, and
after the period for applying leeches has passed, blisters may be
resorted to, and repeated in quick succession, with great advantage.
I have occasionally found a third or a fourth necessary before the
pain has been completely removed. They are equally useful in
cases of considerable effusion, the absorption of which they greatly
promote.
In the repetition of blisters, as well as of leeches, cupping, and
venesection, and in the selection of one of these remedies in pre-
ference to another, much must necessarily be left to the judgment
of the practitioner. It is only experience which can teach the ex-
act adaptation of remedies to the circumstances. It must also be
left to his discretion whether to give sedatives or not. When the
restlessness and nervous irritability were great, I have seen much
benefit derived from tinct. hyoscyami m xv ad xx with the same
quantity of tinct. digitalis, in a draught three or four times a day.
Sedative remedies, however, should not be given until the first
severity of the inflammation has subsided; nor should they ever be
allowed, by producing their poisonous effects, to confuse the symp-
toms, already sufficiently complex, in the latter stages.
During convalescence, it is sufficient to say that a spare, unsti-
mulating diet and extreme tranquillity must be imperatively en-
joined until the action and sounds of the heart have become per-
fectly and permanently natural.
An individual who has recently been affected with pericarditis is
very liable to a recurrence of it: especially if it has resulted from
acute rheumatism and the reparation has been incomplete. In
this case, should the rheumatism return, it rarely fails to be accom-
panied with a renovation of the pericardiac symptoms. This can-
not be a subject of surprise; for it is consistent with general
analogy that a part recently injured by inflammation, is more sus-
ceptible than a healthy tissue of inflammatory action — the reason
of which probably is, that the vessels of newly organised adventi-
10— a 13 hope
194 HOPE ON DISEASES OF THE HEART.
tious structures are more tender and irritable than others. Secondary
inflammation, however, has not the same energy and intensity as
that of a healthy structure, it yields more promptly to curative
measures, and is more completely within the powers of medicine.
Hence a first attack of pericarditis is more dangerous than any sub-
sequent one. It is comparatively rare for a patient to die from the
direct effect of a recurrent attack ; and, what is still more remark-
able, he may sustain several without being left in a materially worse
condition than after the first.
Much discretion, however, is requisite on the part of the practi-
tioner to bring1 such recurrent attacks to a favourable termination,
and the danger of doing too much, is perhaps greater than that of
doing too little. He must, in particular, be cautious of bleeding
too extensively with the object of reducing the excessive energy of
the heart's action ; for this energy, he must recollect, is a conse-
quence, not of the inflammation only, but partly also of an organic
affection of the organ, (viz. hypertrophy or valvular disease,) left
by the primary attack. Nor is there the same motive for a vigorous
employment of mercury ; for, the heart being already irreparably
disorganised, it would be chimerical to entertain the expectation of
effecting a perfect cure. The object, therefore, should be, simply,
to prevent deterioration by combating the inflammation as it pre-
sents itself.
For the accomplishment of this object, a moderate use of blood-
letting and mercury suffices ; and leeching or cupping on the prae-
cordial region is more efficacious and less exhausting than vene-
section. Blisters are, in these cases, peculiarly beneficial, and
they may be repeated in quick succession, on different parts of the
prascordial region, as often as they are required and can be borne.
When there still remains a little lingering pain, which scarcely
authorises vigorous measures, but cannot prudently be left, the most
valuable and convenient remedy has appeared to me to be, a plaster
composed of a scruple of potassio-tartrate of antimony, four scruples
of the emplast. picis comp. and two scruples of wax to diminish the
tenacity of the adhesion.
In these cases, also, where the sufferings of the patient, though
perhaps not severe, are very protracted, and accompanied with
much loss of rest, great advantage is derived from a pill of from
three to six grains of extr. of hyoscyamus at bedtime, and moderate
doses of tincture of digitalis during the day, the specific poisonous
effect of the latter remedy being obviated by omitting it for a couple
of days after every three or four. General dropsy may occur if
there be much impediment to the circulation, and it must be com-
bated with the usual diuretics.
[The views of the author as regards the treatment of the violent forms of
pericarditis are admirable, which in such cases cannot be too prompt or
energetic. But, in the milder, which are the more common forms of the
disease, treatment of thai character would be injudicious, inasmuch as de-
fective cardiac action would be induced, and thus augment the embarrass-
ANATOMICAL CHARACTERS OF PERICARDITIS. 195
ment of the circulation, keep up feelings of faintness and agitation, and
probably lay the foundation of subsequent reaction. Moderate venesection
is preferable, conjoined with topical bleedings, especially cups between the
shoulders, repeated blisters over the precordial region, the moderate exhi-
bition of calomel and the administration of purgatives, etc. p. r. n. — P.]
Treatment of Chronic Pericarditis. — When pericarditis is
essentially chronic, and the cavity appears to contain fluid, coun-
ter-irritant remedies are the most suitable. After what has already
been said, it will be sufficient merely to mention blisters, either in
succession or kept open with savine cerate, the tartrate of antimony
and pitch plaster, and likewise issues and setons. The last remedy,
however, generally creates so much irritation as to do more injury
by deteriorating the general health, than good, by its local effect.
Mercury to a moderate extent, may, if discreetly employed, be ad-
vantageous by promoting absorption ; but, in general, the patient
is too much reduced by constitutional irritation, to admit of more
than the mildest action of this remedy. If general dropsy super-
vene, as I have seen happen in several cases, diuretics must be
used in the usual manner. (See Diseases of the Valves, Treatment.)
The diet may, in chronic cases, be more nutritious, comprising
light animal food and broths.1
1 The reader will be desirous of knowing the treatment, which M. Bouil-
laud has proposed as new and pre-eminently efficacious. The following is
his own account.
"Like all the other inflammations in general, acute pericarditis requires
the use of bleeding, repose, low diet, demulcent and refreshing drinks, and
of emollient applications. Hitherto, this mode of treatment has very rarely
been completely followed out, principally because pericarditis has often been
overlooked, or recognised too late. Now that the diagnosis of this disease
rests on the most certain signs, I dare to affirm that, by employing, with
enlightened boldness, the grand method of bleeding in the treatment of acute
pericarditis;, results truly unlooked for will be obtained. Such, at least, is
the conclusion to which the last years of my experience lead me. Almost
all the cases of pericarditis which 1 have met, have yielded rapidly to copi-
ous bleedings, repeated several times in the space of three, four and five
days. It is unnecessary to say that the bleedings, general as well as local,
should be proportioned to the intensity of the disease, the age, the strength,
the constitution, the sex, the complications, &c The general rule is as fol-
lows:— in a subject in the prime of life, attacked with intense pericarditis,
three or four bleedings from the arm, of three to four 'palettes,' in the three
or four first days, seconded by the application of from twenty-five to thirty
leeches, or by cupping, either being repeated two or three times, will suffice
for the cure of the disease. I leave it to the discretion of the well-informed
practitioner to determine the cases in which he ought to stop within, or to
exceed the mark that we have just fixed. Few cases of pericarditis will re-
sist this treatment, if they are taken at the commencement.
"But if, notwithstanding the assistance of art, suitably administered, the
pericarditis should be prolonged, or should even pass into the strictly chronic
state, it would be necessary to employ a discreet combination of moderate
local bleedings, whether by means of leeches or of cupping, with various
revellents, such as blisters, cauteries, moxas, setons, tartar-emetic ointment,
croton oil, &c. Mercurial frictions may equally be employed.
"A severe regimen, and warm baths repeated from time to time, will
favour the action of the other curative means.
13*
196 HOPE ON DISEASES OF THE HEART.
SECTION VI.— Adhesion gf the Pericardium.1
Pericarditis, both acute and chronic, and especially that origi-
nating in acute rheumatism, frequently terminates in adhesion of
the pericardium. Lancisi, Vieussens, Meckel, Senac, Corvisart,
and more strongly than all Morgagni, are of opinion that, with a
complete and intimate adhesion, the patient cannot live in a state
of health. I know not how it is that Laennec and Bertin and
Bouillaud have formed an opposite opinion. The former states
that he had opened a great number of subjects so affected, who
had never complained of any derangement in the circulation or
respiration ; whence he infers that adhesion often does not in any
respect interfere with the exercise of those functions. (De l'Auscult.
torn. ii. p. 664.) Bouillaud, in his latter work, adheres, though
with a slight qualification, to the same opinion. (Traite, i. 447,
1835.)
" Should the effusion within the pericardium prove rebellious against all
these remedies, the case becomes the most embarrassing possible. The
evacuation of the liquid by a surgical operation, is one of the therapeutic
problems of which experience has not vet given the solution." (Traite, i.
p. 479.)
Such is M. Bouillaud's treatment. It is, in fact, the pure antiphlogistic
plan, (with the exception of purgatives, which he does not even name,) more
actively employed than is common in France, but such as was the ordinary
treatment of acute inflammations in this country for time immemorial, till
the use of mercury diminished the necessity for copious depletion. In the
particulars of M. Bouillaud's plan of blood-letting, there is nothing new. I
do not, indeed, see any difference between his rules and those in the text
above (p. 190). For robust subjects, we both recommend, as the general
rule, three or four venesections and as many local bleedings, in the three or
four first days ; the extent of the depletion being regulated in every case, by
the age, sex, constitution, intensity of the inflammation, &e. Although,
however, our rules are the same in theory, they will issue very differently in
practice; for while his will lead to profuse blood-letting, mine will lead to
very moderate, in consequence of the action of mercury promptly suspend-
ing the indications for it.
The disadvantages of M. Bouillaud's plan are, 1. That profuse bleeding
leaves the patient in a state of anaemic debility, from which he only slowly,
and sometimes never completely recovers. 2. That the plan fails, if com-
menced late. 3. That the effusion within the pericardium is apt to. "prove
rebellious, when the case becomes the most embarrassing possible." 4. That
valvular disease cannot be obviated with any certainty.
M. Bouillaud has, however, great merit for breaking through the trammels
of habit or fashion, and resorting with boldness to the use of the lancet— a
plan far superior to the imbecility of the medecine expectante. It is, per-
haps, reserved for him to confer a further benefit on French practical medi-
cine, by discarding ultra-Broussaian timidity, and exhibiting similar bold-
ness with respect to the use of mercury. He would probably find that this
remedy, discreetly employed, would save twenty lives for every one that
would be sacrificed by gastro-enterite.
1 This should, strictly perhaps, be ranged amongst- the organic affections ;
but as it is in some cases more or less inflammatory long after the adhesion
has taken place, and as it is intimately connected with pericarditis, it can-
not be separated from it without breaking the continuity of the subject.
ANATOMICAL CHARACTERS OF PERICARDITIS. 197
My own experience is entirely opposed to this doctrine. Nor
has the additional experience of seven years, since the preceding
sentence was written, afforded me reason to alter my opinion. I
have never seen an individual with complete adhesion of the peri-
cardium, "enjoying the most flourishing health." (Bouillaud.)
The general health, indeed, may have been flourishing, but there
has invariably been more or less palpitation and hurried respiration
on exertion. The absence of complaint on the part of the patient,
Laennec's criterion, is certainly not a legitimate one; for I have
often found the working classes disclaim dyspnoea even when la-
bouring under enormous hypertrophy and dilatation, and when
that symptom obviously existed in a great degree. I can only
account for this by supposing that, as the symptom supervenes
gradually, they get habituated to it and do not discover that it is
other than their natural state. J have heard some admit, indeed,
that they were "short-winded," but ascribe it to "weakness."
Many others also, especially children, are naturally inattentive to
their own sensations, and close interrogation is the only mode of
ascertaining that, after the attack of pericarditis, they became inca-
pable of some exercises, habits, or efforts which they previously
accomplished with facility.
Further. I have never examined, after death, a case of complete
adhesion of the pericardium without finding enlargement of the
heart, — generally hypertrophy with dilatation. This sufficiently
demonstrates the tendency of the affection. 1 have observed that
cases of adhesion terminating in enlargement, often hurry to their
fatal conclusion with more rapidity than almost any other organic
affection of the heart: and J have,, on the other hand, repeatedly
seen patients die from the consequences of an adhesion, the history
of which T could trace back eight, ten, or more years; yet such
individuals would, not an frequently, represent their health to have
been perfect during the greater part of that period, and would not
admit, until closely interrogated, that they had been more or less
"short-winded." Hence I infer that, though close adhesion may
not. for a time, create much inconvenience, its effects are ultimately
fatal, especially in the working classes. A tranquil, abstemious
life, by which, in other forms of organic diseases of the heart, exist-
ence may sometimes be prolonged to its natural period, may do
much, but cannot be equally availing here ; for, as the action of the
organ itself is a constant struggle, repose is impossible.
How adhesion occasions hypertrophy is easily understood; for,
first, inflammation is probably a cause of hypertrophy; and,
secondly, the organ must increase its contractile energy, in order
to contend against the obstacle which the adhesion, by shackling
its movements, presents to the due discharge of its function; and,
as explained in the article on hypertrophy, increased action leads
to increase of nutrition. The cause of the co-existent dilatation is
not less manifest. As the shackled organ transmits its contents
with difficulty, it is constantly in a state of greater congestion than
198 HOPE ON DISEASES OF THE HEART.
natural, and, as is more fully explained in the article on dilatation,
permanent distention is the most effective cause of this affection.
When the muscular substance has been softened by the previous
inflammation, as frequently happens, dilatation takes place much
more readily, in consequence of the deficient elasticity or tone of
the heart's parietes. When valvular disease, from endocarditis
complicating the pericarditis, accompanies adhesion, it will, of
course, contribute its part to the production of the hypertrophy and
dilatation, which must not, therefore, in such cases, be attributed
to the adhesion alone.
When adhesion of the pericardium has produced hypertrophy with
dilatation, its history identifies itself with that of the latter maladies,
of which it renders the symptoms more severe and the progress
more rapid. To avoid repetition, therefore, I refer the reader to the
article on hypertrophy, and shall, here, only describe the signs
which are pathognomonic of adhesion.1
These signs have generally been considered very obscure. Dr.
Sanders believed that he had discovered one of a positive nature in
a dimple or retraction taking place, as he states, during the ventri-
cular systole, in the epigastrium immediately below the left false
ribs, and which he ascribes to the diaphragm being drawn in by
the ascending movement of the heart. I have searched for this at-
tentively in several cases of adhesion, but have not been able to
detect it in any degree which could constitute a sign. Laennec,
who was equally unsuccessful, thinks that it could not take place
unless the stomach, by adhering both to the diaphgram and the ab-
dominal parietes, formed the medium of retraction, for the. dia-
phragm alone would merely draw in the false ribs.
M. Bouillaud says that " he is not yet acquainted with any sign
1 ["It is a common notion among pathologists, that an adherent pericar-
dium is in some degree secure from attacks of inflammation ; but this is a
great mistake. I have frequently found in both layers of pericardium, and
in the false membranes which unite them, traces of inflammation, such as
punctuated and striated redness, softening of the membrane, and an effusion
of lymph and a little serum, or a sero-purulent liquid, into their interstices,
and into the adjoining cellular membrane in the mediastinum. Of course
there can be no quantity of liquid effusion into an adherent pericardium ;
but under these circumstances this very commonly takes place into one of
the pleural sacs instead. The exacerbation to which those affected with old
rheumatic disease of the heart are occasionally subject, often originate in
inflammation of the pericardium, or the internal lining membrane. An ad-
herent pericardium has no immunity from these attacks; in fact, from its
being so constantly fretted and strained by the inordinate motions of the
heart, it may be conceived to be particularly liable to them ; and if they oc-
casion death, the appearances found are such as I have described. These
inflammations of an adherent pericardium cannot give the signs that are
usually distinctive — the friction sound, or the dulness and deficient impulse
of effusion. Hence, unless their presence is indicated by local pain, tender-
ness, or soreness, it can only be suspected, on the occurrence of more than
usual irregularity and excitement in the action of the heart, unaccompanied
by other sufficient cause." — C. J. B. Williams'1 Lectures on Diseases of the
Chest.— P.]
ANATOMICAL CHARACTERS OF PERICARDITIS. 199
by which we can detect adhesion of the pericardium in particular."
(Traite, i. p. 467.)
I certainly consider this diagnosis to be one of the very few con-
nected with the heart, which cannot be made with absolute cer-
tainty, and I never, therefore, venture to assert respecting it ; yet,
in the great majority of cases, I have succeeded with much ease in
detecting the affection by the following combination of signs :
1. In five or six cases (and, since this was published seven years
ago, I may now say a much greater number) I have remarked one
sign, which has not, to my knowledge, been hitherto noticed by
others : namely, the heart, though enlarged, and when, therefore,
it ought to beat preternaturally low down in the chest, beats as
high up as natural, and sometimes occasions a prominence of the
cartilages of the left praecordial ribs. (Cases of May, Harrison, a
boy, Payne, &c.) We should, indeed, naturally expect that the ad-
hesion would brace up the organ, and that, when enlarged and not
able to descend, it must, being bounded behind by the spine, force
the walls of the praecordial region forward.
2. Another sign, equally unknown to authors, and perhaps the
most characteristic of all, is an abrupt, jogging, or tumbling motion
of the heart, very perceptible in the praecordial region with the
cylinder. It is more distinct when the heart is hypertrophous and
dilated4; and, under these circumstances, I have found the jogs cor-
respond with the ventricular systole and diastole respectively, that
of the diastole being sometimes nearly as strong as the other, and
having the character of a receding motion suddenly arrested. (Cases
of May, Payne, Harrison, a boy.) This jogging motion is distin-
guished from the undulatory movement of fluid in the pericardium,
both by its nature, by the exact synchronism of the jogs with the
sounds, and by the feeling that the heart, at each systole, comes in
immediate contact with the thoracic walls. I suppose the double
jog to be occasioned by the heart being bound down to the spine by
the adhesion, whence it is tilted forwards as often as the rounded
swell of the ventricles, both during their systole (see causes of the
impulse, p. 85) and their diastole, (see Experiments, p. 40.) meets
the resistance of the spinal column. This view is corroborated by
the same double jog having occurred in a case of aneurismal tumour
behind the heart, though there was no adhesion of the pericardium
and little enlargement of the heart. (See Physical Signs of Aneu-
rism of the Aorta.) The jogs would, of course, be increased by
hypertrophy, and also by aortic regurgitation, which imparts abrupt-
ness to the heart's action.
3. A history of previous pericarditis, especially if connected with
acute rheumatism, affords strong presumptive evidence corroborat-
ing the above signs : and the absence of such history should make
the auscultator pause before he ventures on a diagnosis of adhesion
in stronger terms than that " it is probable or possible."
200 HOPE ON DISEASES OF THE HEART.
CHAPTER II.
CARDITIS, OR INFLAMMATION OF THE MUSCULAR SUBSTANCE.
Inflammation of the muscular substance of the heart may be,
1. universal ; 2. partial.
1. Of universal carditis with effusion of pus generally through-
out the muscular tissue, there is not, to my knowledge, more than a
single instance on record, and that occurred to Dr. Latham. " The
whole heart," says he, " was deeply tinged with dark-coloured blood,
and its substance softened ; and here and there, upon the section
of both ventricles, innumerable small points of pus oozed from
among the muscular fibres. This was the result of a most rapid and
acute inflammation, in which death took place after an illness of
only two days."1 Laennec, never having met with, or heard of, a
case of this kind, and considering an effusion of pus the only
unquestionable sign of carditis, says, "there does not perhaps exist
a single incontestable and well-described example of general inflam-
mation of the heart either acute or chronic."2 Independent of the
above instance, however, there are probably many others, which,
though not attended with effusion of pus, will come under the de-
nomination of universal carditis. For few will concur with this
distinguished writer in excluding from the proofs of carditis, soften-
ing and induration, with increased, or diminished colour of the
organ. These are results of inflammation in other muscles, and
analogy points out that they may have the same origin in the heart.
Further evidence is derived from the fact that, in cases of peri-,
carditis, the characters in question sometimes occupy only a certain
depth of the exterior surface of the organ ; whence the presumption
is almost positive that they originate in an extension of the inflam-
mation from the pericardium. The cases of this description that
are on record, are too numerous to be quoted. Several have fallen
under my own observation. In this point of view, then, carditis
is not very rare.
As softening and induration are of sufficient importance to
demand separate articles, I refer the reader to them, especially to
softening, for all that remains to be said on general carditis. They
are introduced amongst the organic, rather than the inflammatory
affections, because, authors are not entirely agreed whether they
result from inflammation or from other causes, a question which I
have considered in the article Softening.
With respect to the symptoms and treatment of carditis, they are
the same as those of peri- and endo- carditis, because general car-
ditis never exists as an independent affection, and because, when
complicating the membranous inflammations, it does not present any
set of signs peculiar to itself, though it greatly aggravates the gene-
1 Lond. Med. Gaz. vol. iii. p. 118. 2 De l'Auscult, ii. p. 554,
INFLAMMATION OP THE MUSCULAR SUBSTANCE. 201
ral aspect of the case. I "think it may be regarded as the cause of
the feeble, fluttering, irregular, intermittent action of the heart, with
suffocative symptoms, when these phenomena cannot be accounted
for by the presence of fluid in the pericardium or of polypous con-
cretions from endocarditis. For the symptoms and treatment, there-
fore, the reader is referred to Pericarditis.
2. Partial carditis, characterised by the existence of an abscess
or ulceration in the walls of the heart, is not very uncommon.
Bonetus, in his Sepulchretum, has described a considerable num-
ber of cases. Abscesses are more rare than ulcers. The latter
occur both on the external and the internal surface of the heart,
and are consequent on inflammation of the membranes of those
surfaces. The external ulcer is uncommon, but Olaus Borri-
chius, Peyer, and Graetz have left perfect descriptions of it. The
first says " Cordis exterior caro, proiunde exesa, in lacinias et villos
carneos putrescentes abierat." The internal ulcer is more common.
Bonetus, Morgagni, and Senac present many cases. I have met
with two or three.
An ulcer, whether external or internal, may perforate the heart
and cause sudden death by effusion of blood into the pericardium.
A perforation of the interventricular or interauricular septum may
not be fatal, but will generally give rise to cyanosis. Couillaud
says that there are cases in which it does not produce any serious
symptom. I have difficulty in conceiving this, and suspect that the
cases were too cursorily observed.
The signs of abscesses and ulcers vary in different subjects, and
are not distinguishable from those of other affections. "I know
not," says Laennec, " if auscultation will afford any more sure signs,
and I avow that I think not/' My own observation hitherto verifies
Laennec's prediction. Bouillaud also says thai "no positive and
characteristic sign announces the existence of simple ulcerations
and of abscesses of the heart. On this subject,. unhappily, all
pathologists are agreed." (Traite, i. 303. )'
Ulceration is the most frequent cause of rupture of the heart, —
fortunately a very rare occurrence. Rupture independent of ulcer-
ation generally originates in disease of the muscular tissue, by
which its cohesion and resisting power are diminished : — softening
for instance. I have met with one instance, mentioned in the article
on dilatation. Haller and Morgagni describe many. It is generally
in the left ventricle that the rupture takes place, a circumstance
which at first appears remarkable, since this ventricle is the
stronger ; hut, for the same reason, it contracts more energetically,
and, as the rupture occurs during the contraction, we have thus an
explanation of the phenomenon. It might be objected that suppos-
ing the strength of the muscle and the energy of its contraction to
be in the direct ratio of each other, the explanation offered would
1 For partial dilatation or false consecutive aneurism of the walls of the
heart, the reader is referred to the chapter on that subject amongst the
organic affections.
202 HOPE ON DISEASES OF THE HEART.
not account for the phenomenon. To this it may be replied, that it
is only strong muscles which do undergo rupture from the energy
of their own contraction. Hence rupture of the auricles is much
more rare than that of the ventricles.
The exciting causes of rupture are, generally, considerable
efforts, paroxysms of passion, external violence — as falls, &c.
Corvisart was the first who noticed and described cases of rup-
ture of the fleshy columns and tendinous cords of the heart: Laen-
nec and Bertin have each met with an instance of the same. Violent
efforts, as coughing, were the cause ; the symptoms were, sudden
and very severe suffocating dyspnoea, with overwhelming faintness,
paleness and coldness, followed by all the general phenomena of
disease of the heart. I have met with five or six cases of regurgita-
tion, some through the aortic, and others through the mitral valve,
which I believe to have originated in rupture or laceration of the
valves, because the patients dated their malady from some violent
effort, suddenly followed by the symptoms enumerated in the preced-
ing sentence. In such of the patients as I examined after death,
the suspected valve was found diseased and permanently open. In
one case with similar symptoms (see case of Milton,) an aneurism of
the aorta had burst into the right ventricle : in another, the diseased
internal and middle coats of the aorta appeared to have cracked. I
should always, therefore, regard the sudden occurrence of the
symptoms in question after an effort, as indicative of some serious
rupture; the nature of which may, with very few exceptions, be
readily ascertained by the physical signs of valvular disease ex-
plained in the chapter on that subject, and in the diagnosis of
aneurisms on the pulmonary artery.
Rupture of the heart or great vessels into the pericardium is not
always immediately fatal, as a solid coagulum or a fibrinous concre-
tion has in several instances been known to arrest the hasmorrhage
for a few hours (Case by Cullerier. Journal de Med. par M.M.
Corvisart, Serone et Boyer, Sept. 1806, t. xii. p. 168). Often cases
mentioned by M. Bayle ei^ht died instantaneously, one in about
two hours, and another in fourteen. (Revue Med.)
[Dr. HalloweH, of this city, has communicated to the American Journal
of the Medical Sciences for 1835, an excellent paper on the rupture of the
Heart, in which he reports two cases occurring under his observation in the
Hopital Salpetriere at Paris.
" The number of well attested observations of Rupture of the Heart," he
says, "amount perhaps to sixty." Of these he has given the analysis of
thirty-four, in which it is stated, "that the patients had been affected for a
greater or less length of time, with palpitations, and had experienced fre-
quent attacks of lipothymia, or complained of pain beneath the sternum,
and tightness and weight across the chest, &c." The accidents usually
occur in persons in advanced life. Of the thirty four cases collected by Dr.
Hallowell, the age is precisely stated in twenty-three- only ; of these, nine
were between seventy and eighty, six between sixty and seventy, five
between fifty and sixty, two between forty and fifty, and one between
twenty and thirty, (from dilatation.) Sixteen of the thirty-four individuals
were males, and eighteen were females.
INFLAMMATION OF THE INTERNAL MEMBRANE. 203
The rupture occurs, for the most part, in the left ventricle, in its anterior
wall near its middle. In the above mentioned cases, the place of rupture
is stated in thirty-one. Of these there were three ruptures of the right
auricle, none of the left, two of the right ventricle, and the remaining
twenty-six of the left ventricle.
The rupture varies in size from an almost imperceptible aperture, to a
slit an inch or more in length. It may be single, or there may be several.
" The tissue of the heart, surrounding the place of rupture, will be found
in one of the following conditions.
1. In a perfectly healthy state.
2. In a state of ulceration.
3. Hypenrophied with or without ramollissement, or softening.
4. Softened to a greater or less extent.
5. Dilated and thinned.
6. To have become the seat of a partial dilatation.
7. To have undergone a fatty degeneration." — P.]
The existence of gangrene of the heart has never been distinctly
proved, and the following reasons lead to the belief that its occur-
rence is perhaps impossible ; first, the muscular tissue is one of
those least susceptible of it; and secondly, inflammation of the
heart sufficiently intense to occasion it, is fatal to the patient before
gangrene can take place. The cases on record of reputed gan-
grene, appear to have been nothing more than softening, which
incipient putrefaction had rendered more analogous to gangrene.
CHAPTER III.
ENDOCARDITIS, OR INFLAMMATION OF THE INTERNAL MEMBRANE
OF THE HEART.
Preliminary Observations. — To M. Bouillaud the merit is due
of having been the first to draw attention in a decided manner to
inflammation of the internal membrane of the heart and great
vessels, which had been either overlooked or only cursorily
glanced at by Corvisart, Baillie, Burns, Kreisig, P. Frank, and
Laennec. "In 1824 and 1826," says he, "I already possessed
a sufficient number of facts tu have a glimpse (entrevoir) of all
the importance of inflammation of the heart and great vessels.
But those facts did not yet permit me to treat this rich and fertile
subject with all suitable minuteness : hence, the ideas which I
broached were regarded by many physicians of great authority as
purely theoretical." (Traite, ii. p. 1, 1835.) This neglect may be
attributed mainly, I think, to the manner in which M. Bouillaud
treated his subject : for he concentrated his attention principally
on aortitis — a disease so obscure that it might well be supposed
theoretical, while he almost overlooked the immense importance
of endocarditis, and certainly failed to throw any correct light on
its symptoms. For instance, he devotes three pages to the signs
204 HOPE ON DISEASES OF THE HEART.
of aortitis, and dismisses endocarditis with the following passage :
" As to independent inflammation of the membrane of the heart,
it is excessively rare .-1 Analogy indicates that it ought to be
characterised by augmentation of the force and frequency of the
beats of the heart, when it is not sufficiently violent to diminish,
suspend or entirely arrest the action of that organ. Observation
confirms that which analogy leads us to foresee. In fevers pro-
perly so called, which appear to me to be invariably accompanied
with irritation of the heart, the frequency and force of the pulse
are the two principal phenomena which strike our attention : if
the fever assumes a grave character, and occasions so serious
(profonde) an irritation of the heart, that the muscular substance
itself of the organ becomes affected, the pulse loses in force and
regularity, while it increases in frequency, and an unexpected
death frequently terminates this always formidable complication."
(Traite du Cceur par M.M. Bertin et Bouillaud, p. 69, 1324.)
As this doctrine of fever was not considered sound, it increased
the belief that M. Bouillaud was describing an imaginary disease.
Another reason why he excited opposition to his own views,
was, that he ascribed, with too little qualification, all varieties of
redness and all kinds of depositions in the heart and aorta to in-
flammation. In his recent work he disavows having done so, and
repels the charge as a misapprehension of others ; for, says he,
"I had declared in the most express manner, that, amongst those
varieties of redness, there were some purely cadaveric or from
imbibition of blood after death." (torn. ii. p. 2.) This declaration,
however, I have not been able to find in the Traite du Cceur of
M.M. Bertin and Bouillaud in 1824; nor is there, in that work,
any reference to a Treatise on Fevers, cited in his later "Treatise
on the Heart in 1835." After describing, in the Traite in 1824,
all the varieties of redness, including one which he compares to
a stain, (and which every one now admits to be nothing else,)
he finally says, "We have considered the redness to be the result
of inflammation, whatever was its shade." The utmost qualifi-
cation of this opinion that I find, is, "If any shade of redness
can, in fact, be regarded as not inflammatory, it is beyond con-
tradiction that in question (viz. violet). New facts are necessary
to enable us to pronounce in a positive manner on its true cha-
racter .... In conclusion, the violet, brown and even blackish
colour, is not a decisive reason for rejecting the idea of inflam-
mation ; for many inflammations of the skin and mucous mem-
branes, and, amongst others, those which manifest a gangrenous
tendency, are accompanied with livid, violet, brown or blackish
redness." (Traite, par M.M. Bertin et Bouillaud, p. 55 and 56.)
Now, surely, this is almost the opposite of a ^'declaration in the
1 M. Laennec had said, " Inflammation of the internal membrane of the
heart and greai vessels is a very (foit) rare affection :" thus he follows
Laennec with respect to endocarditis.
INFLAMMATION OF THE INTERNAL MEMBRANE. 205
most express manner, that there were some (varieties of redness)
purely cadaveric or from imbibition of blood after death."
With respect to depositions, he says, " The yellow points, the
cartilaginous patches, the calcareous and plaster-like incrustations
of the aorta, appear to us to be nothing more then a series of
metamorphoses successively passed through by the matter se-
creted by inflammation." (p. 58.) Such being M. Bouillaud's
opinions in his own words, he must necessarily be under some
mistake in disavowing them and imputing misapprehension to
others.
I was not one of those who rejected the opinions of M. Bouil-
laud as "theoretical," though, as will presently be shown, he
erroneously states that I was. I adopted his account of red-
ness as far as he now (1S35) admits himself; but I pursued
the train of reasoning followed by Laennec (because no better
was necessary) to prove that redness was sometimes a result of
sanguineous imbibition, and to show how the latter might be dis-
criminated from the inflammatory kind. I have not seen cause
to alter this train of reasoning in the present edition. Further,
I gave a full account of the anatomical changes indicating what
I considered to be, really, inflammation of the interior of the heart
and aorta (1st edit. p. 148) : again, amongst the exciting causes
of diseases of the valves, 1 specified " inflammation of the in-
ternal membrane of the heart, resulting from carditis, pericar-
ditis— especially rheumatic, from fever or from any other cause"
(p. 319) ; lastly, I discovered and published the grand pathogno-
monic signs of acute endocarditis, namely, the valvular murmurs,
at a time when they were not only unpublished, but possibly un-
suspected by M. Bouillaud ; for he states (Traite, ii. p. 2) that he
conducted his researches on acute endocarditis especially, during
the years 1832-3 and 4, when my work, published in Dec. 1831,
(though dated by the publisher 1832,) was accessible to him. It
cannot be said, therefore, that I had not, in 1831, both recognised,
corrected and extended the very limited and imperfect researches
of M. Bouillaud on endocarditis. During the ensuing three years,
I had so far widened my observation, that, when his work ap-
peared in 1835, I can frankly say that the article endocarditis
scarcely contained a material fact to which I was a stranger.1
1 The above remarks evince, I will not say the injustice^ (because, as M.
Bouillaud is said to be unacquainted with the English language, he may
only have been mistaken,) but the incautious inaccuracy of the following
observations in his last Treatise. " In the chapter devoted to the inflamma-
tion of the interior of the heart and arteries, Dr. Hope has scarcely added
anything to what had already been -published on the subject by me in 1824,
and he has thought proper to make himself in some sort, the echo of all that
M. Laennec has said against the intervention of appreciable inflammatory
action, which I had admitted as the point of departure of a certain number
of lesions, called organic, of the valves of the heart or of the walls of the
aorta. Further, like Laennec, Dr. Hope teaches us absolutely nothing, either
206 HOPE ON DISEASES OF THE HEART.
SECTION I. — Anatomical characters of Acute Endocarditis.
The anatomical characters of acute endocarditis are, redness of
the internal membrane of the heart and arteries, an effusion of
lymph or pus on its surface, and thickening, softening and ulcera-
tion of its substance and of the subjacent cellular and fibrous tis-
sues ; also, according to M. Bouillaud, the presence of adherent,
colourless coagula of blood. Each of these characters will be con-
sidered in succession.
A. Redness of the internal membrane of the heart and arte-
ries.— This is sometimes inflammatory, and sometimes not. We
will first notice the latter.
1. Redness not inflammatory, often appears in the aorta, the
pulmonary artery, and the heart, and is a uniform, intense colour,
as if stained by the blood. Corvisart (p. 36) avows that he cannot
give a satisfactory account of its nature and cause. P. Frank
regarded it as an inflammation of the arteries, which, according
to him, occasioned a peculiar and almost always fatal fever (De
Curand. Homin. Morbis, torn. ii. p. 173). Bertin and Bouillaud
" have considered it, whatever was its shade, as the result of in-
flammation." (Traite, p. 55.) Laennec entertains an opposite
opinion, and demonstrates satisfactorily that the redness in ques-
tion, when not accompanied by other anatomical characters of
inflammation, is the result of sanguineous imbibition.1 As it is
necessary that the reader be able to judge for himself, I shall give
on the causes or on the diagnosis of inflammation of the internal membrane
of the heart:' (Vol. ii. p. 6.)
He proceeds, " It is seen from what precedes, to what estate of penury, if
I dare so express myself, medicine was reduced on the important point
which occupies our attentiou. The new facts which I have collected during
the last three years, (1832, 1833 and 1834,) permit me, however, to affirm
that inflammation of the internal membrane of the heart is, contrary to the
opinion of M. Laennec, a disease really very common, and as frequent as
pericarditis itself."
It is but justice to my countrymen to say that not only this fact, but almost
every other of importance which M. Bouillaud has published either on endo-
carditis or pericarditis, is to be found in the works of Dr. Latham, Dr. El-
liotson, Dr. Stokes and myself, all published not only before M. Bouillaud's
Treatise, but, with one exception, (Dr. Stokes in 1832,) before he had even
commenced his researches on endocarditis in 1S32. I may add that he is
still singularly in the rear in his diagnosis of endocarditic valvular affec-
tions ; since he does not even pretend to specify the particular valve dis-
eased, the mode of accomplishing which I had distinctly pointed out in 1831,
but which is brought to the utmost nicety in the present edition.
1 It might be added, or when not preceded by distinct physical and general
signs of acute endocarditis ; for these signs, when distinct, are so unequivo-
cal that I agree with M. Bouillaud in thinking them-sufficient to prove the
redness inflammatory, provided the subject be not opened later than twenty-
four hours after death ; as, after this period, the colour may result from putre-
factive imbibition.
INFLAMMATION OF THE INTERNAL MEMBRANE. 207
some account of this redness, adhering to the description of La-
ennecj which I have verified by repeated experiments and dissec-
tions.
The redness is sometimes scarlet, and sometimes brown or
violet.
a. The scarlet redness of the interior of the arteries is often
confined to the internal membrane exclusively ; and, when that
membrane is removed by scraping with the scalpel, the subjacent
cellular tissue and the fibrous coat are found as pate as in their
natural state. But in other cases the redness penetrates more or
less deeply into the fibrous coat, and sometimes it reaches, in
parts, even the cellular or external tunic. The redness of the
internal coat is a perfectly uniform tint, similar to that which
would be presented by a piece of parchment painted red. No
trace of injected capillaries can be distinguished in it; but the
tint is sometimes deeper in one part than another. Sometimes
it diminishes insensibly from the origin of the aorta to the place
where the redness ceases : but, very often, it terminates suddenly,
forming abrupt borders of an irregular shape. Sometimes, in
the midst of an intensely red portion, is found an accurately
circumscribed patch of white, which produces precisely the effect
that is occasioned by an impression of the finger on a part of the
skin affected with phlegmon or erysipelas. When the aorta con-
tains very little blood, the redness only exists in the tract in
contact with it, and forms a sort of ribbon. The origin and arch
of the aorta are the parts of that artery which are the most fre-
quently found thus reddened. Sometimes nearly all the arteries
present the stain. The aortic and mitral valves participate in it,
and appear as if they had been immersed in a red dye. Though
the red is scarlet in the arteries, it is deeper on the valves, ap-
proximating slightly to purple or violet. This proceeds merely
from deficiency of the opake white ground, which enriches the
colour in the aorta by reflecting light.
When the pulmonary artery is reddened, its valves and the tri-
cuspid are also very commonly stained in the same way. The
stain of the right cavities and vessels of the heart is always of a
deeper and browner hue than that of the left — a circumstance
dependent, in all probability, on the darker colour of the venous
blood. The internal membrane, where it invests the muscular
substance of the ventricles and auricles, sometimes does not pre-
sent any sensible change of colour, even when the valves are
vividly reddened. More commonly, however, it participates in
the redness, but exhibits a darker, and more violet or browner
hue, simply in consequence of the ground being deeper.
The redness described is not accompanied with any sensible
thickening or vascular injection of the stained membranes. It is
not removed by washing, but a few hours, maceration in water
suffices to make it totally disappear.
208 HOPE ON DISEASES OF THE HEART.
Such are the characters of the scarlet redness. We next come
to-
ft. -The brownish or violet stain. It is found equally in the
aorta, the pulmonary artery, the valves, the auricles and the ven-
tricles. Most commonly, indeed, it is observed in all these parts
simultaneously. .It is often very unequal in intensity, and is
always deeper on the parts of the vessels which, according to the
laws of gravity, have been most in contact with the blood. Its
shade is, of course, less deep on the valves and in the arteries
than over the muscular substance, because this forms a darker
ground. It is not so commonly restricted to the lining membrane
as the scarlet redness ; for the muscular substance of the auricles
and ventricles, and even the fibrous tunic of the aorta and pul-
monary artery, usually participate in the dye, — at least in some
points and to a certain depth.
Such is Laennec's account of redness of the internal membrane.
But redness, he contends with great justice, is not sufficient to
characterize inflammation, particularly when it is not accompa-
nied by thickening or vascular injection of the reddened parts.
Moreover, the abrupt circumscription of the redness, in some
cases, within geometrical, though irregular lines, (an appearance
never seen in inflammation of serous membranes, though it pre-
sents itself occasionally and to a slight degree in that of mucous,)
banishes the idea of inflammation, and conveys that of a stain by
a coloured liquid, which had run irregularly on the reddened
membrane, and, on account of its deficient quantity, had not
been able to touch every part.
Again, the circumstances under which the redness is usually
found, countenance the idea of its being a stain, rather than from
inflammation. Thus, Laennec found the scarlet red to occur
after a somewhat protracted agony in subjects still vigorous, but
cachectic in consequence of disease of the heart or some other
malady. The blood in these cases was never very firmly coagu-
lated, and the body most frequently presented some signs of
decomposition.
The brownish or violet red, he found in those subjects espe-
cially, who had died of continued typhoid fevers, of emphysema
of the lungs, or of diseases of the heart. Almost all had experi-
enced a long and suffocating agony: in all, the blood was very
liquid and evidently altered, and signs of premature decomposition
existed in the bodies. I have myself also very constantly found
it in cachectic subjects affected with passive haemorrhage from the
gums, from ulcers, or from any tender or broken surfaces, — as in
scurvy and purpura. It is, moreover, in summer particularly,
and in subjects that are opened more than twenty-four hours after
death, that the dark discoloration is most frequently met with.
Both varieties of redness, and particularly the brownish or vio-
let, are accompanied with a greater or less degree of softening of
INFLAMMATION OF THE INTERNAL MEMBRANE. 209
the heart, and with an increased humidity of the arterial walls.
In most instances, these states are evidently the effects of a com-
mencement of putrefaction.
The cases which Bertin and Bouillaud have adduced in sub-
stantiation of their opinion that the redness in question is of an
inflammatory nature, are strikingly corroborative of the opposite
views of Laennec. For, of twenty-four cases, eleven are typhoid
fever, or other affections, in which there was a manifest alteration
of the liquids, and premature putrefaction. The thirteen other
cases consist almost entirely of consumptive patients; and the
writers observe, in general terms, that the redness appeared to
coincide with a remarkably fluid state of the blood. It must,
further, be remarked that most of their examinations were made
in summer, and more than thirty hours after death.
In order to ascertain experimentally whether blood could occa-
sion a stain, Laennec enclosed a quantity in a sound and recent
aorta, and placed the preparation in the stomach of the subjects,
in order to preserve it from drying, and to put it under the same
circumstances of decomposition as the rest of the body. In
twenty-four hours it presented a perfect specimen of the scarlet
dye, which was not weakened by reiterated washing.
He found that blood, too firmly coagulated, causes imbibition
feebly and slowly : that blood half coagulated, and particularly
the blood, still slightly florid, which may be pressed out of the
lungs, produces the scarlet redness : that very liquid blood, and
particularly that with a serous intermixture, produces a violet
colour of greater or less depth : and that if the artery be only
partly filled, the dye occupies those parts alone which are in
contact with the blood, thus forming a ribbon. If the walls of the
artery are firm and elastic, the dye, he continues, requires a long
time (seventy or eighty hours) for its formation, and is never very
deep ; but if, on the contrary, the walls are soft, supple, and
charged with humidity, the dye promptly penetrates through the
whole thickness. Warm weather and the rapid progress of putre-
faction are favourable to the imbibition.
Boerhaave and Morgagni also attributed the red colour to the
stagnation of blood which takes place during the agony in diseases
accompanied with great oppression ; and Hodgson likewise main-
tains that arterial redness, such as that above described, does not
arise from acute inflammation, as it is not accompanied by any
other anatomical characters of inflammation. When occurring in
the vicinity of coagula, it is. he thinks, an effect of imbibition after
death.
It is impossible not to conclude from all the evidence now ad-
duced, first, that redness of the internal membranes of the heart
and arteries cannot alone prove inflammation ; secondly, that it
is a phenomenon taking place during the agony, or after death,
whenever it is found in conjunction with the following circum-
10— b Uhope
210 HOPE ON DISEASES OF THE HEART.
stances : namely, a prolonged and suffocative agony ; manifest
alteration of the blood; and a somewhat advanced decomposition
of the body.1
Such is the redness of the internal membrane of the heart and
arteries which is not inflammatory. We now proceed to that
which is.
2. The colour of inflammatory redness may be the same ; for
the membrane, though inflamed, is still liable to imbibition. In
the absence of imbibition, the redness is fainter, less shining, more
equably diffused, and less characterised by streaks, patches, isolated
unstained spots, and abrupt edges. The further proofs that it is
inflammatory, fall under the next head. The absence of all red-
ness does not exclude the idea of inflammation ; for, in other serous
membranes, when slight, it sometimes disappears after death.
B. Effusion of lymph on the internal membrane^ with thicken-
ing of its substance. — Whether redness be due to vascularity
alone, or to this, conjoined with imbibition, its inflammatory nature
is known by the presence of other anatomical characters of inflam-
mation. These are, thickening, swelling, and puffiness of the
inner membrane, especially about the valves; an effusion of lymph
on either its free or adherent surface ; and a preternatural vas-
cularity, with softening and thickening, of the middle arterial coat.
Each of the coats, also, may be separated from the other with
much greater facility than natural, by scraping with the nail or
scalpel, in consequence of softening of the interposed cellular
tissue. The internal and middle coats and their connecting cel-
lular tissue, in short, present all the phenomena of the adhesive
inflammation as it displays itself in other membranes. It is by
this inflammation that, if an artery be wounded or divided ; if it
be compressed by a ligature or tumor; or if it be simply irritated
by ulceration of the surrounding parts or a pulmonary vomica,
an effusion of lymph takes place into the cavity of the vessel and
1 Though M. Bouillaud has denounced me as the echo of Laennec
against inflammation, he has himself come round to my views, and repro-
duced, almost totidem verbis, the conclusions in the text. The following
are his words : —
First, "I do not think it possible to decide by simple inspection, nor by
washing or maceration itself, whether a given redness of the internal mem-
brane of the heart be the effect of inflammation or of cadaveric imbibition.
It is necessary therefore to search elsewhere for the means of resolving this
important question."
Secondly, "I have convinced myself by a great number of facts, that
certain varieties of redness of the heart and vessels are nothing more than
a purely cadaveric imbibition; and I have ascertained, in-common with a
great number of other observers, that these latter varieties of redness exist
almost constantly in individuals opened at a time when putrefaction of the
body is already more or less advanced, especially ff those individuals have
died of a disease which has been accompanied by putrid or typhoid pheno-
mena— in which case the blood is more liquid than in the normal state, a
circumstance that renders it more susceptible of imbibition by the internal
membrane of the vascular svstem.
INFLAMMATION OF THE INTERNAL MEMBRANE. 211
into the cellular tissue, both investing it externally and connecting
its several coats together, by which the caliber of the vessel is ob-
literated and haemorrhage prevented.
Lymph has been found effused on the unattached surface of
the lining membrane within the auricles and on the valves, by
Baillie,1 Laennec,2 and Burns.3 I have met with it both in the
heart and aorta.4 Effusions of lymph within the heart and great
arteries, however, are very seldom found; and hence it is. that
Laennec thinks inflammation of the internal membrane of those
parts extremely rare. (De l'Auscult. ii. p. 498.) But the presence
or absence of lymph is not sufficient to determine whether inflam-
mation exists or not; for, in many instances, the lymph, when first
effused, is unquestionably washed away by the force of a circula-
tion so powerful as that in the heart and aorta. The same remark
applies still more strongly to pus. It is, however, as Bouillaud
well remarks, "sometimes concealed in the centre of coagula, or
detained in the meshes formed by the columnas carneae."
Kreysig, Hodgson, Bertin and Bouillaud, and Bouillaud in his
later work, are of opinion that lymph effused by inflammation is
the source of fungous or warty vegetations of the valves. Laen-
nec rejects this opinion, and attributes the vegetations to sanguine-
ous concretions, which adhere to the internal membrane and
become organised. He does not deny, however, that an inflam-
matory false membrane may become the nucleus of these concre-
tions. 1 once caused the deposition of granulations in an hour,
by lacerating with a hook the pulmonic valves and interior of the
right ventricle of an ass poisoned with woorara (see p. 71 ;) which,
I think, militates in favour of the inflammatory origin of vegeta-
tions, as the general rule ; but it is probable that the cause assigned
1 Morbid Anat. Edit. 5, p. 85.
* De l'Auscult. torn. ii. p. 127.
3 On Diseases of the Heart, chap. 9.
4 The three preceding paragraphs demonstrate the inaccuracy of M.
Bouillaud's representation, that I had denied the intervention of inflam-
mation as a cause of redness and morbid organic changes. Subjoined are
his own criteria, the anatomical parts of which are identical with those in
the text: the semeiological part (viz. endocarditic murmurs, &c.) I had
published before himself, as already shown at p. 205.
" In my opinion," says M. Bouillaud, " we may consider as of an inflam-
matory nature a redness of the internal membrane of the heart, existing in
an individual whose body has been opened before any trace of decomposi-
tion had shown itself, and which had presented during life the symptoms
that we shall assign in the following article to inflammation of the internal
membrane of the heart. But the inflammatory nature of the redness will
be still more evident if, to the circumstances just specified, the following
conditions be united; 1. swelling, thickening, and tumefaction of the parts
occupied by the redness ; 2. the presence of a certain quantity of pus, of
false-membranous matter, or even of those adherent, colourless coagula,
which resemble the inflammatory buff of the blood or fibro-albuminous
lumps (pelotons); 3. the co-existence of similar redness in blood-vessels,
the inflammation of which was positively ascertained before the death of
the patient." (Traite, ii. p. 173. 1S35.)
14*
212 HOPE ON DISEASES OF THE HEART.
by Laennec is occasionally real. This subject will be more fully
considered under the head of Vegetations.
[The opinion of Bouillaud, Hodgson, &c, above cited, is supported by-
strong pathological facts. We frequently meet with indubitable evidence
of inflammation of the internal membrane of the heart; thus, in the laminse
of the valves, and near the auricula-ventricular orifices, is often seen in the
endocardium punctuated patches of vascular redness, frequently accom-
panied by an inequality, roughness, or softness of the membrane, whh films
of lymph lying upon it. To the edges of the valves, or upon an inequality
which the lining membrane presents, are attached fibrinous vegetations,
evidently organised. Or, if the acute stage of the disease has passed, then
are presented changes, which, in other structures are regarded as evidence
of the result of inflammation, such as the thickening, induration, ossification
of the lining membrane and valves. — P.]
C. Ulceration of the Internal Membrane. — Ulceration of the
internal membrane sometimes takes place from acute inflamma-
tion, and it may exist without occasioning any lesion of the sub-
jacent tissues. One instance is given in Case 50 of Bouillaud
(ii. p. 48). I think, however, that acute ulceration is rare; for,
in general, ulceration is manifestly a consequence of some pre-
vious chronic degeneration of the coats of the vessel, and is, in
the first instance, rather a solution of continuity than an ulcera-
tion. Such is the case when it is occasioned by the detachment
of calcareous incrustations, or by the deposition of atheromatous
or other matter underneath the internal membrane. As these
depositions are rare under that part of the membrane which
covers the muscular substance, we see the reason why ulcers are
seldom found within the cavities of the heart. Still, I have seen
four or five instances of this in a chronic form.
I have never seen or heard of a case in which endocarditis
manifestly terminated in gangrene. Bouillaud, however, has col-
lected four or five cases in which "he is tempted to think that
the very rapidly fatal termination was attributable to an endo-
carditis strongly analogous to certain gangrenous inflammations."
(See torn. ii. p. 176, and Cases 22 and 39.) These cases, though
open for consideration, are far from being conclusive, as a pre-
viously diseased state of the blood would sufficiently account for
the symptoms which they presented.
Coagulation of the blood within the heart, as a consequence of
acute endocarditis, is a phenomenon of which I have no personal
knowledge, because I have never witnessed a fatal case of this affec-
tion : but I entertain no doubt of its reality ; first, because such
coagulation is a well-known result of phlebitis and arteritis ; and,
secondly, because M. Bouillaud, who has been more fortunate in
seeing fatal cases, gives the following account of the coagulation : —
"It results from the numerous cases of acute endocarditis given
in my first category, that this inflammation commonly induces, as
its consequence, the coagulation of a greater or less quantity of the
blood which circulates through the cavities of the heart. In this
respect endocarditis resembles arteritis and phlebitis. The concre-
SIGNS AND DIAGNOSIS OF ENDOCARDITIS. 213
tions of blood formed by acute endocarditis must not be confounded
with the ordinary clots met with in the heart, especially those
formed after death. The concretions consequent upon acute endo-
carditis are white, colourless, elastic, glutinous, adherent to the
walls of the heart, twisted round the valvular tendons and fleshy
columns. They are in a manner half organised, and, as I have
already said, strongly analogous to the inflammatory buff of the
blood, or to false membranes themselves : some occasionally pre-
sent red points and lines, which are really nothing more than rudi-
ments of vessels.
" The concretions in question differ much in volume and con-
figuration. They extend pretty commonly into the great vessels.
They are, cseteris paribus, larger and more abundant in the right
cavities than in the left. Their most adherent part is generally
about the free border of the valves, where some fragments may still
remain after reiterated washing. It is probable that these little
fibrinous masses may become organised or transformed into vegeta-
tions or granulations." (Traite, ii. p. 178.)
Such are the anatomical characters of acute endocarditis. It is
scarcely necessary to add, that, if resolution and complete absorp-
tion do not take place, the thickening of the lining membrane be-
comes permanent. Lymph adhering to its surface becomes or-
ganised. Laennec thinks, as already stated, that adherent coagula
of blood occasionally undergo the same change. Lymph deposited
beneath the lining membrane, also becomes organised. Though
the valves are its principal seat, it does occur, and occasionally in a
very marked degree, under the membrane investing the muscular
substance ; for 1 lately saw an instance in which several masses, as
large as peas and horse-beans, existed under the membrane of the
left ventricle. In slighter cases, we see this membrane present a
mottled opacity from subjacent thickening. The whole of these
accidental depositions, especially those connected with the valves,
may, according to the laws of Analogous Transformations, pass into
the successive states of fibrous tissue, cartilage and bone. For all
the details on this subject, the reader is referred to the section on
the Anatomical Characters of Diseases of the Valves. It may be
finally stated that it is these ultimate organic changes, constituting
incurable and often fatal disease of the heart, which render endo-
carditis one of the most important and formidable diseases in the
nosology.
SECTION II.— Signs and Diagnosis of Endocarditis.
This subject need not detain us long, as most of the signs are
analogous to those of pericarditis, which, in the great majority of
cases, complicates endocarditis. I therefore thought it desirable to
include a pretty complete notice of endocarditis in the chapter on
Pericarditis, because, as the latter name is familiar to practitioners,
214 HOPE ON DISEASES OF THE HEART.
it will continue to be turned to for a considerable period before the
new, but appropriate term endocarditis, which owes its origin to
M. Bouillaud, becomes universally known.
It has appeared to me that endocarditis more frequently exists
without pericarditis, than this without the other. M. Bouillaud
gives 34 cases of endocarditis, of which one-half were exempt from
pericarditis. I shall assume, in the following account, that the en-
docarditis is uncomplicated.
General Signs. — Inflammatory fever exists in a greater or less
degree, but its symptoms are suspended when great embarrassment
of the circulation supervenes, and are replaced, as will presently be
shown, by the symptoms of apnsea.
Pain is represented by Bouillaud to be entirely absent, except
when it is attributable to co-existent pericarditis or pleuritis. I
think that this is rather overstated, as I have several times noticed
a slight pain in apparently pure endocarditis. Though there be
no pain, there is always an undefinable "uneasiness" in the pre-
cordial region, often attended, I have observed, with a somewhat
anxious, distracted expression of countenance. It will presently
be shown that this uneasiness amounts to insupportable distress
when the circulation through the heart becomes greatly impeded.
Here the symptoms (as in pericarditis) branch off into two widely
different classes, according, 1. as the circulation through the heart
continues free; 2. as it becomes greatly obstructed by valvular dis-
ease or polypi.
1. When the circulation continues free, the action of the heart,
stimulated by the inflammatory irritation, is violent and abrupt.
The increased extent over which it is perceptible is, I think, pro-
portionate to this violence, rather than to inflammatory turgescence
of the organ, as supposed by M. Bouillaud. I have known a tre-
mour about the 4th or 5th left intercostal spaces, accompany the
impulse when there was regurgitation through the mitral valve.
The pulse, corresponding with the action of the heart, is, as a
general rule, full, strong, hard and regular, but there are occasional
exceptions in weakly, nervous subjects. Aortic regurgitation ren-
ders it jerking, and sometimes imparts a thrill to the arteries when
the circulation is strong. Its frequency I have found to range prin-
cipally between 80 and 110.
Respiration is slightly accelerated, as in other inflammatory
affections; but, while the patient is at rest, there is little or no
oppression.
The circulation being free, there is no purpleness or pufliness of
the face, or oedema with coldness of the limbs, indicating venous
retardation : nor any wandering of the mind, from the circulation
of venous blood through the brain.
This series of symptoms constitute a very supportable form of
disease, — more so even than pericarditis without effusion of serum;
for in the latter there is often pain, and, consequently, a constrained
position on the back. Still, it must never be forgotten that, mild
SIGNS AND DIAGNOSIS OF ENDOCARDITIS. 215
as is this form of endocarditis, it is equally dangerous in its ulti-
mate results, — valvular disease, as the most distressing form next
to be described.
2. When the circulation through the heart becomes greatly im-
peded, whether from the orifices being obstructed by a tumid and
contracted state of the valves, or from their admitting of free regur-
gitation, or from the blood coagulating and choking up the cavities
of the heart, or entangling and impeding the action of the valves,
another class of symptoms, of the most distressing kind, presents
itself — a class analogous to that produced in pericarditis by much
fluid in the pericardium compressing the heart, and which was
pointed out by the writer as also characteristic of polypus, inde-
pendent of endocarditis, when formed before death (see Signs of
Polypus, or p. 511 of the 1st edit.)1 I believe, however, that when
cases of acute rheumatism and of inflammation of the heart are treated
in the way that I have pointed out, (p. 186 and p. 190,) the severe
symptoms in question will be of very rare occurrence : — at least, I
have never seen them in a considerable degree. T therefore admit
them principally on the authority of M. Bouillaud. They arc as
follows.
The action of the heart becomes irregular, unequal, intermittent,
and exceedingly quick, attaining from 130 to 160 or more beats in
a minute. Sometimes, beats are dropped in the pulse which exist
in the heart, every contraction of the organ not expelling blood
enough to propagate an undulation into the arteries.2 The im-
pulse is sometimes simultaneously violent, from the struggle of the
heart against the obstacle; but it ultimately becomes feeble and
fluttering from exhaustion.
The pulse is generally small, weak, irregular, unequal and inter-
mittent, and this may be the case though the impulse be violent
and tumultuous; for, says M. Bouillaud, the large fibrinous con-
cretions in the ventricles, and the obstructions in the valves, are
circumstances which, in spite of the violence of the heart's contrac-
tions, prevent the projection of a large column of blood into the
arteries. When there is free aortic regurgitation, the pulse will, of
course, be jerking.
From this defect of arterial circulation results ghastly paleness,
coldness, mortal faintness and actual syncope, overwhelming
anxiety of mind and countenance, perpetual jactitation, and an ago-
nizing feeling of suffocation which confines the patient to the erect
position, and prevents the possibility of a moment's sleep.
The venous circulation being retarded, any redness of the face
and hands becomes purple or livid, and, if the patient survive a
1 The same symptoms are produced by paralysis of the heart from poi-
sons: they therefore indicate any extreme impediment to the circulation
through the heart, whatever be its cause. This analogy is interesting and
instructive.
2 M. Bouillaud introduces this as "a new species of disaccord." It was
fully described in the first edition of this work, p. 331-2.
216 HOPE ON DISEASES OF THE HEART.
few days, dropsy may show itself in puffy intumescence of the face
and sedema of the lower extremities. The mind, too, may wander
a little, from the circulation of venous blood through the brain ;
and, occasionally, when this organ becomes much congested, there
may be sudden insensibility, slight convulsive movements, stertor-
ous respiration and foaming at the mouth. These symptoms oc-
curred in two cases recorded by Bouillaud. (See torn. ii. p. 208.)
The class of severe symptoms now described very rarely exists
in a marked degree dissociated from the mechanical causes to which
they are ascribed. Yet, in a few cases, I have known weakness,
irregularity, intermission and inequality of the beats of the heart,
together with orthopncea, anxiety and distress, to exist temporarily
and in a moderate degree, though the general context of the cases
led me to judge that there was no great mechanical impediment to
the circulation through the heart. The same may occur in peri-
carditis without serous effusion. Here then we see the interven-
tion of a disturbed state of the nervous system, and we must no
more overlook its occasional and possible influence in these cases,
than when the symptoms in question result, as they often do, from
a mere fit of dyspepsia, bile, gout or hysteria.
Physical Signs. 1 — Percussion is dull over a surface of 4, 9,
and even 16 square inches. M. Bouillaud, if 1 understand him,
ascribes this to " turgescence of the heart, from the inflammatory
fluxion.'' (Tom. ii. p. 205.)
I cannot easily comprehend how the walls of the heart can sim-
ply s well to such an extent; but 1 can readily conceive that the
effect might be produced by distention of its interior by polypi or
blood ; for, in experiments on rabbits poisoned with woorara, I have
seen the heart swell to nearly double its natural size from engorge-
ment, when artificial respiration was temporarily suspended. (See
p. 45.) I am disposed to think, therefore, that increased dulness on
percussion will be slight or absent in cases of endocarditis where
.the circulation is free, and exist in a high degree in those only, in
whom there is a great impediment to the circulation, attended with
the second, or distressing class of general signs above described.
Dulness from this cause may be discriminated from that produced
by fluid in the pericardium by the impulse (when not imperceptible
from feebleness) sensibly striking the walls of the chest, and by its
being exactly synchronous with the first sound ; whereas in hydro-
pericardium it is indistinct, undulatory, and not synchronous.
Further, the dulness of much fluid in the pericardium mounts
higher up the sternum than that from endocarditis.
Impulse. — This is violent, abrupt and regular, so long as the
circulation through the heart is free. When it is greatly impeded,
as indicated by the weak, irregular pulse, the "impulse may for a
1 M. Bouillaud says, these "have not yet been noticed by any author" (ii.
204.) He is mistaken: he forgets that he himself commented in his previ-
ous volume (p. 200), on my account of the valvular murmurs of endocarditis,
where he also alludes to the labours of Dr. Stokes and Dr. Latham,
SIGNS AND DIAGNOSIS OF ENDOCARDITIS. 217
time continue violent, but it is an irregular, confused tumult; and
this violence generally subsides into a feeble, unequal flutter as the
obstruction increases and the nervous power fails.
Sounds. — If the inflammation has caused constriction of either
set of sigmoid valves, or permanent patency of either auricular valve
allowing regurgitation, a murmur will attend the first sound, and it
may proceed either from the sigmoid valves alone, the auricular
alone, or from both conjointly.
If the inflammation has caused permanent patency of either set of
sigmoid valves, with regurgitation, a murmur will attend ihe second
sound. I think that it seldom if ever proceeds from contraction of
the auricular valves.
In the vast majority of cases, the murmurs are confined to the
left side of the heart. It is obvious that if polypi should almost
choke up the passage through the heart, the murmurs would dimin-
ish or wholly cease, as there would not be a sufficient current of
blood to produce them.
For the mode of easily ascertaining which is the particular valve
affected, the reader is referred to Valvular Disease, Physical
Sig-?is ; and. for the Diagnosis of valvular, from attrition-murmurs
occasioned by pericarditis, he is referred back to p. 182.
[Endocarditis, like pericarditis, is intimately associated with acute arti-
cular rheumatism, and it occurs more frequently even, than the inflammation
of the external cardiac tunic. It is also of frequent occurrence as a second-
ary consequence of pneumonia, pleurisy, and of the inflammation of the
serous tissues. But, although it is thus frequently a complication of other
diseases, it is often presented as a primitive affection.
Like pericarditis, the rational signs of its existence are sometimes so ob-
scure, that the disease, without the means which we possess of forming a
diagnosis based on physical signs, would be entirely latent. The extent of
dulness upon percussion of the precordial region, as stated in the text, is
occasionally found to be greatly augmented, but it may be distinguished
from that arising from precordial effusion by the impulse of the heart being
more forcible, and its beat quite superficial, instead of being, as in pericarditis,
remote and indistinct. The action of the heart at the commencement of the
disease is very forcible, and is perceptible, when the hand is applied upon
the chest, over an unusual extent.
But the auscultatory signs are of a more distinctive character, and reveal
one of the most striking evidences of the existence of the disease; it is the
blowing- murmur in the first sound, varying in intensity from the gentle
whiff to the most intense rasping sound, according to the intensity of the
disease, the thickening of the valves, and the force of the cardiac circulation.
The action of the heart is frequently so violent, that the abnormal rasping
sound is so great as entirely to mask the natural sounds. The systolic
sound, however, is generally observed to be much prolonged, and is often
double, arising most probably from a want of synchronism in the contraction
of the different parts of the muscular parietes.
The second sound, at the commencement of the disease is sometimes also
accompanied by a blowing murmur, — but, as the heart becomes congested,
this sound is heard very indistinctly, and when the organ is surcharged with
blood, or coagula have formed in its cavities, the second sound is annihi-
lated.
The abnormal murmur attendant upon the first sound may be produced by
the passage of the current of blood at the aortic orifice, and also by the regur-
218 HOPE ON DISEASES OF THE HEART.
gitation at the mitral valve, the closure of which is rendered incomplete by
the distended state of the heart and by the irregular spasmodic action of the
columnar carnea?. If the roughened first sound be heard louder near the left
nipple, near the point where the apex beats, than at the aortic valves, it
should be ascribed, principally, to the regurgitation through the auriculo-
ventricular orifice ; but, if the abnormal murmur be heard most distinctly
over the upper third of the sternum, especially opposite the cartilages of the
second ribs, the lesion causing the sound exists at the aortic valves.
As the disease advances, the heart becomes very irregular in its pulsa-
tions— the ventricular systole seems to be spasmodically performed; it often
reaches one hundred and forty to one hundred and fifty per minute, whilst
the pulsations at the wrist are weak, intermittent, irregular, or they may be
entirely absent. A marked vibratory movement is frequently observed be-
tween the third and fourth left ribs, probably occasioned by regurgitation
through the left auriculo-ventricular orifices. Coincident with this stage
of the disease, the action of the heart is embarrassed by the formation of
coagula in its internal cavities, arising, as has been observed by Kreysig and
Bouillaud, from a highly fibrinous state of the blood. This in fact is an es-
sential element of the disease, and, as has been observed by Doctor Gerhard,
" it is yet more frequently a cause than an effect of endocarditis, and may
be generated by any other inflammation, and thus re-act upon the lining
membrane of the heart."
The oppression, dyspnoea, jactitation, and extreme anxiety arising from
the congested state of the heart is often extreme ; evidence of venous ob-
struction is seen in the tumid and purple appearance of the face and lips, the
lungs and internal viscera become surcharged with blood, and, in protracted
cases, cellular infiltrations supervene.
The great majority of cases of the disease terminate in recovery, but when
it remains unsubdued for some time, endocarditis lays the foundation of or-
ganic changes of the valves, which ultimately produce the most unfortunate
results. — P.]
Summary. — Such are the general and physical signs of endo-
carditis, and I may now sum up by stating that this affection may
be anticipated if a person be suddenly attacked with three signs :
1. Fever; 2. Violent action of the heart; 3. A valvular murmur
which did not previously exist, provided the murmur be well
distinguished from an attrition-murmur, as the latter indicates
pericarditis. The evidence is still stronger if the signs occur in
connection with acute rheumatism.
SECTION III. — Causes, Progress and Duration, Terminations, Prognosis and
Treatment of Endocarditis.
The Causes of endocarditis are the same as those of pericarditis,
(see p. 184,) to which phlebitis, extending to the heart, may be
added.
Progress, Duration and Terminations. — If the treatment of
endocarditis be commenced early and conducted vigorously, and
especially if acute rheumatism — its ordinary cause, has been treated
on the principles explained in the preceding chapter, (p. 186, note,)
the disease may, according to my experience, generally be divested
of all danger to life in three or four days or a week : M. Bouillaud
CAUSES, PROGRESS, ETC. OF ENDOCARDITIS. 219
calculates eight days to be about the average term ; but he does not
employ mercury. I feel satisfied that complete cures, without a
trace of murmur from valvular disease remaining, may be effected
in a considerable proportion of cases within the term which I have
specified — and more readily, indeed, within this period than after-
wards; for I have observed, that when a murmur continues more
than a week or ten days, it is apt to resist for several weeks longer,
and sometimes permanently: which, indeed, is what we should
expect : for when the morbid products of inflammation have once
become organised, (and this process may commence in less than a
week,) they are far more difficult to remove.
If the murmur should persist beyond a week or ten days, the
endocarditis may be regarded as passing into the chronic stage,
and this may continue for several weeks or even months, and still
be benefited by antiphlogistic treatment. After this, if the murmur
be not subdued, the affection enters into the list of established val-
vular diseases; which, if neglected,, may ultimately compromise
life, but if suitably treated, may, as will be shown in the Section
on the Treatment of Valvular Diseases, be prevented, in a large
proportion of cases, from producing serious consequences.
The termination of endocarditis in valvular disease has, I fear,
been by far the most common up to the present time, especially
amongst the working classes. This is in conseouence of endo-
carditis having been little known as an effect ot acute rheuma-
tism ; whence the treatment of the latter was not specifically
directed to the obviation or removal of the former. In proof of
this, I may repeat a statement already made, that I have found
the worst forms of valvular disease to date more frequently from
" rheumatic' fever," (by which is to be understood rheumatic
endocarditis,) than from all other causes put together. The eyes
of the profession are now attentively directed to this subject ;
and it is to be hoped that it will soon become one of the best
known, because most important, in medical science — one, in short,
of which it will be disgraceful to be ignorant.
["As far as my observation goes, I should state that those signs indicating
the affection of the aortic orifice are less enduring than those of the mitral
orifice; but whilst they last, they are commonly attended with more con-
stitutional disturbance, and give to the pulse a sharp jerking character. It
probably requires a more considerable lesion in this orifice to produce sounds
than in the mitral orifice. In the latter situation, the properties regulating
the action of the valves are so readily deranged, both by inflammation and
by its effects, that the blowing murmur which is heard there often becomes
more or less constant, or is produced whenever the circulation is accelerated.
The degree in which the regurgitation may prove injurious, will chiefly
depend on its extent, and on the state of the general circulation. If the
heart's propulsive power be weak, or the regurgitation considerable, which
may often be known by the lower or deeper tone of the murmur, there will
generally be more or less dyspncea, especially on lying down or on lying on
the left side, sometimes with feelings of faintness or palpitation, and per-
haps cough ; palpitation always on exertion ; sometimes an unequal or
irregular pulse'; and occasionally more or less pain in the left side. But if
220 HOPE ON DISEASES OF THE HEART.
the action of the heart is pretty effective, and the regurgitation slight, which
may be known by the more whiffing or whistling character of the murmur
below the breast, there may be little or none of any of these symptoms.
But almost in all cases the regurgitation will induce secondary effects, by
slightly, but constantly, backening the venous circulation, and causing
gradual congestion in many viscera, which may more or less derange their
functions, according to their proneness to disorder. Hence occasional
gastric and hepatic derangements, or 'bilious attacks,' from accumulated
congestions in the portal system; these are very common: attacks of
asthma and pituitous catarrh, from pulmonary congestion ; and attacks of
head-ache, drowsiness, or giddiness, from stagnation of blood in the sinuses
of the brain." — C. J. B. Williams's Lectures, $c— P.]
The Prognosis of endocarditis may be collected from what has
now been said. The acute affection, with good diagnosis and
treatment, is rarely fatal. But, according to M. Bouillaud, it
may be fatal " in the space of a few days, and then, most com-
monly, one of the principal causes of death is the formation of con-
cretions of blood in the cavities of the heart." (Traite, ii. p. 232.)
Chronic endocarditis presents a gloomy remote prognosis, in con-
sequence of the probability of confirmed valvular disease.
The Treatment suitable for acute endocarditis is the same as
that for pericarditis, (see p. 190,) and it must not be less prompt
and vigorous. The practitioner must not be misled by the appa-
rent mildness of the symptoms in cases where there is little impedi-
ment to the circulation through the heart. He must never, for an
instant, forget, that there is a possibility of subsequent valvular
disease, and that the mere possibility is a contingency of such
magnitude, as to merit all the resources of his abilities and experi-
ence for its obviation.
In chronic endocarditis, I have experienced the most satisfactory
results from prolonging the mild use of mercury, so as to maintain
a barely sensible effect on the gums, for three, four, five, or six
weeks ; simultaneously employing a succession of small blisters
on different parts of the precordial region, restricting the patient
to a farinaceous and light broth diet, and confining him to bed,
for the purpose of ensuring the utmost possible corporeal tran-
quillity.
Should the murmur still resist, the mercury may be discontinued,
and its future resumption must be left to the judgment of the prac-
titioner; but the counter-irritant, antiphlogistic treatment, in a mo-
derate degree — that is, short of reducing the patient to a state of
anaemic debility, together with quiet and the use of digitalis and
mild sedatives, as extr. hyoscyami and tr. or infus. lupuli, may be
advantageously continued for several months, with the view of
completely subduing the chronic inflammatory process, and allow-
ing any thickening that has already taken place, to undergo the
utmost possible absorption. Beyond this, the treatment resolves
itself into that of established valvular disease, for which the
reader is referred to the chapter on that subject.
ACUTE ARTERITIS. 221
CHAPTER IV.
ACUTE AND CHRONIC ARTERITIS, AND ORGANIC DISEASES OF
THE COATS OF ARTERIES.
Acute Arteritis. — The anatomical characters of acute
arteritis are the same as those of acute endocarditis, described
at p. 206; but they are much more difficult to ascertain, because
lymph, pus, and coagula are seldom found in the aorta, and the
tumefaction of its coats is not so easily appreciated as that of the
valves. It is still more difficult, if not totally impossible, to as-
sign to acute arteritis any particular set of symptoms, because it is
perhaps always complicated with endocarditis, by which its own
symptoms are, as it were, absorbed : to speak more explicitly,
the two diseases are essentially one and indivisible. Hence it
was, that, before endocarditis was thoroughly understood, the
symptoms common to both were, by Bertin and Bouillaud,
ascribed principally to aortitis. In the first edition of this work,
I pointed out the numerous fallacies in the symptoms assigned
to aortitis, and its extreme obscurity as an abstract, disease. It
is unnecessary now to retrace the same ground, as M. Bouillaud
himself has, in his later work, suppressed aortitis and its sup-
posed symptoms, and judiciously concentrated his attention on
its belter half— endocarditis.
One form of acute arteritis may, however, be briefly glanced
at, as an affection to which much attention has been directed by
surgeons. I allude to what they have denominated, though with
very questionable propriety, erysipelatous arteritis, — an affection
which results from injury of an artery, as by a ligature, a gun-
shot wound, &c. — especially if there be deep-seated disease in
the muscles of the affected part. The inflammation, in these
cases, sometimes runs along the internal coat of the artery till it
reaches the heart. It is stated to be a most formidable disease,
rapidly producing great irritative fever, an extremely quick pulse,
complete collapse, low delirium, and generally death. I suspect
that the essence of this disease does not consist in its supposed
erysipelatous nature, but in pus having found its way into the
circulation, derived either from the deep-seated muscular injury, or
from suppuration of the fibrinous coagulum in the injured portion
of the artery. This is what we positively know to occur in phle-
bitis, the symptoms of which are identical with those assigned
above to erysipelatous arteritis. That the local inflammation may,
in the latter, be propagated to the heart, is consistent with analogy,
because it is well ascertained that the same occurs in phlebitis. I
have, in two or three instances, known venesection to cause endo-
carditis, and M. Bouillaud's five first cases of this disease, were
connected with phlebitis. (Traite, ii. p. 9.) There is still another
point in which the analogy is preserved ; when a considerable
222 HOPE ON DISEASES OP THE HEART.
artery is suddenly plugged up by coagula from inflammation,
gangrene of the limb speedily ensues : if a great vein be similarly
plugged, dropsy of the parts beyond is the result.
I have never seen or heard of a case in which inflammation,
when confined to the interior of an artery, terminated in gangrene.
Arteries, however, are frequently involved in the sloughing of sur-
rounding parts ; in which case, the blood generally coagulates in
the vessels to a considerable extent above the line of sphacelation,
and thus prevents haemorrhage (Hodgson, p. 17).
Chronic Arteritis. — Arteries are more subject to chronic,
than to acute inflammation. The internal membrane, when
affected with it, is thickened, softened, and of a deep, dirty red
colour. These appearances are not uniformly diffused, but are
more marked in the vicinity of calcareous, steatomatous, and other
degenerations. Hence some have supposed that these degenera-
tions were the cause of the inflammation. There can be little
doubt that they tend in many instances to keep it up; but it is
highly probable that the degenerations themselves were originally
caused by increased vascular action of a chronic nature. Since
writing this in the first edition, I have seen nature engaged, as
it were, in the very process. An intelligent student of St. Bar-
tholomew's Hospital brought me a specimen of the aorta, in which
the cellular tissue and fibrous coat were of a dim and pretty deep
Indian red colour, with increased lacerability, behind patches and
spots of the internal membrane, where opake, steatomatous yellow-
ness, with thickening and elevation of the surface, were beginning
to appear. There were also valvular vegetations. Acute rheuma-
tism had preceded. Mr. Haydon guessed the age to be 22.
The appearances in arteries presented by chronic inflammation
accompanied with morbid depositions, have been well known to
authors from a very early period. The ancient physicians ascribed
them to acrimonious, syphilitic, and scorbutic humours pervading
the system. Some modern writers also, particularly Corvisart,
Scarpa, Richerand and Hodgson, impute them to similar causes,
especially to the syphilitic virus, or the mercury used for its eradi-
cation. After bringing the degenerations themselves under review,
I shall revert to the consideration of their causes, as some difference
of opinion on this point has existed amongst authors during the
last twenty years.
Morbid alterations in the coats of Arteries, and especially the
Aorta. — The morbid alterations in the interior of the aorta which
appears to be of chronic formation, are, steatomatous, fibrous, car-
tilaginous, and calcareous depositions, with a thickened, fragile,
and inelastic condition of the arterial coats: also ulcers and pus-
tules.
Before describing the depositions, it may be premised that they
originate, not in the internal coat, but either in the middle coat, or
in the fine cellular tissue interposed between it and the internal
coat; that the latter coat can sometimes be peeled off from them in
CHRONIC ARTERITIS. 223
a perfect state, even when they are far advanced ; and that the
productions themselves are more analogous to those of cellular and
fibrous, than of serous membrane.
The extent, the form, and the thickness of the productions are
infinitely various. Sometimes the several species exist separately,
but, more commonly, they are found more or less intermingled in
the same artery. The most simple morbid alteration is, a loss of
elasticity, generally accompanied with increased density and opacity,
of the coats of the artery. This state is sufficient of itself to give
rise to dilatation, because (as will be more fully explained under
the head of dilatation of the aorta) the elasticity and tone of an
artery are the powers by which it resists the distending force of the
blood.
The next, and the most common appearance, is that of small,
opake, straw-coloured spots, immediately underneath the lining
membrane, with slight inequality and corrugation of the mem-
brane around them. At a more advanced period, the depositions
form considerable, slightly elevated patches, which, becoming con-
fluent, sometimes overspread the whole surface. Some of these
patches have much the appearance and consistence of bee's-wax,
or cheese, though in general their cohesion and flexibility are
greater. These are usually denominated steatomatous. Others,
presenting nearly the same colour, have a fibrous or ligamentous
appearance; while others, again, are more translucent, white, and
elastic, like cartilage or fibro- cartilage. 1 imagine that the steato-
matous patches are merely imperfectly organised fibrine; that the
fibrous are the same, more perfectly organised ; and the cartilagi-
nous, the ordinary transformation of the fibrous.
All the depositions described are accompanied with thickening
and loss of elasticity of the internal coat, which becomes knotty,
wrinkled, and sometimes cracked, scaly, and fimbriated. This
state of the internal coat, however, is less marked before earthy
depositions have taken place.
Earthy depositions generally commence in the midst of a carti-
laginous or fibro-cartilaginous patch, though they are sometimes
found in detached scales, and sometimes in the midst of steatoma-
tous, cheesy, curdy, or melicerons matter, the softer varieties of
which occasionally present the calcareous element, not in a con-
crete form, but plastic, like putty or mortar. When the earthy
deposits form incrustations, the shape of these is irregularly flat-
tened. Their external surface sometimes presents the imprint of
the circular fibres of the middle tunic. Their internal surface is
sometimes smooth, and evidently covered by the membrane; in
other cases it is rough, and the membrane is more or less destroyed.
Calcareous depositions are more frequent in the ascending portion
and arch of the aorta, but, occasionally, they pervade the whole of
the vessel, and even almost the whole of the arterial system. I
saw a case in the Hotel Dieu, in which the great arteries from the
heart to the ankle were converted into rigid tubes, by ossification,
224 HOPE ON DISEASES OF THE HEART.
which, in parts, occupied all the coats and the whole circumference
of the vessels. In another case, at St. George's Hospital, the com-
mon iliacs were rigid, and one, which was converted into a bony-
cylinder, was obliterated by a plug of dense lymph. The arterial
system was elsewhere more or less ossified. Both the patients died
with gangrenous sores of the legs, — the well-known result of ossified
or otherwise obstructed arteries, and the consequent defect of local
circulation.
In the arteries at the base of the brain, calcareous and other
degenerations are remarkably frequent, and are a principal cause
of rupture of the vessels, and apoplectic effusion. It is rare, indeed,
to meet with instances of such effusion, exclusive of those from
external violence, in which some disease of these arteries may not
be detected. The arteries below the pelvic divarication of the
aorta are more frequently ossified than those of the upper extremi-
ties and trunk.
Calcareous concretions differ essentially from natural bone. For,
though some are formed by the secretion of the earthy phosphate
in cartilage, even these have not the pecular organised arrangement
of bone. But, in by far the greater number of cases, the earthy
matter is not secreted in any cartilaginous matrix, being simply
deposited in the form of an irregular, homogeneous crust or crystal-
lisation, without any determinate arrangement, and without vitality.
The proportion of animal matter in these is very small. Mr.
Brande found 100 parts to consist of 65,5 of phosphate of lime and
34,5 of animal matter. In some specimens I have found the quan-
tity of animal matter considerably less.
When ossification is very considerable, it is sometimes attended
with induration, inelasticity, and fragility, not only of the internal,
but of all the arterial coats ; and this state I have seen attended in
some cases with thickening, and in others, though less frequently,
with attenuation and a horny transluceney of the walls of the ves-
sel. In two cases of the latter, the walls were, in four or five small
spots, as thin and transparent as a serous membrane. The aorta,
so affected, generally undergoes dilatation, but very rarely contrac-
tion. When the depositions are partial and limited, the internal
membrane in the intervals is often perfectly sound. This is espe-
cially the case in the ossifications of old people.
It is remarkable, that though morbid depositions are so frequent
in the aorta, they are extremely rare in the pulmonary artery. Out
of upwards of a thousand cases, in which I have examined this
vessel, I have only once met with a calcareous deposition in its
coats, (case of Lady R.,) and only three or four times with cartila-
ginous and steatomatous disease and dilatation.
Ulcers occurring in the arteries are, in general, a consequence of
some previous chronic degeneration of the coats of the vessel.
Such is the case when they are occasioned by the detachment of
calcareous incrustations, or by the deposition of atheromatous or
other matters underneath the internal membrane. Ulcers from
CHRONIC ARTERITIS. 225
these causes are not uncommon. They vary in size from that of
a mustard-seed to that of a pea or bean, have more or less thick
and ragged edges, and are sometimes so deep as to reach, and even
to perforate, the external or cellular tunic. Laennec describes the
formation of these ulcers from calcareous incrustations, in the fol-
lowing manner. " When a calcareous incrustation is detached
from the aorta, the species of sinus left by it is filled up by fibrine,
which becomes, by decomposition, of the consistence of friable
paste, and is often intermixed with phosphate of lime." This
paste, when soft and pulpy, has been denominated melicere or
atheroma. Not unfrequently, the borders of the lesion are reddened
for a little distance. Solutions of continuity, and ulcers connected
with the detachment of calcareous incrustations, are among the
most frequent causes of consecutive false aneurisms.
Small pustules, filled with pus, sometimes, though rarely, pre-
sent themselves under the internal membrane of the aorta, and
burst into its cavity. It is probable that they form the genuine or
primitive ulcers of that vessel — those which are the most frequent
cause of its perforation. They sometimes throw out curdy, and
even calcareous matter. Laennec thinks that these pustules are
occasioned by inflammation, not of the internal, but of the middle
arterial tunic, or of the fine cellular tissue which unites the middle
to the internal tunic. Pus is scarcely ever found on ulcers of the
heart and arteries, because it is washed away as soon as secreted.
The Causes of Morbid Depositions in the Coots of Arteries. —
Some authors, as M. Buuillaud, in his conjoint work with M.
Bertin in 1824, have considered morbid depositions in the coats of
arteries to be, in every case, the various metamorphoses of lymph,
effused by inflammation. Others, again, of whom Laennec is the
chief, have supposed that many, if not all, of the depositions in
question, take place wholly independent of inflammation of any
kind. As principles of treatment of a decided nature have been
founded on each of these conflicting doctrines, it is a matter, not of
mere speculation, but of practical importance, to examine the sub-
ject, and endeavour to ascertain the truth.
Analogical evidence derived from other membranes leads to the
belief that chronic inflammation is, in most instances at least, the
main agent concerned in the production of these depositions. Thus,
for example, the dura mater, and the pleura or its subjacent cellu-
lar tissue, are sometimes not only thickened and indurated, but
converted into fibrous, cartilaginous, or bony tissue. I have seen
the dura mater converted into a calcareous plate nearly as large as
the hand, and overspreading one hemisphere of the brain. The
preparation was shown to me by my friend Professor Monro, and is
in his museum. Mr. Hammick showed me two preparations in his
museum of calcareous plates, of about two inches in diameter, on
the pleura. Changes of this kind are, by general consent, attributed
to chronic inflammation; as they are not only found in conjunc-
tion with organised adventitious membranes and other anatomical
10— c 15 hope
226 HOPE ON DISEASES OF THE HEART.
proofs of that form of inflammation, but are often attended with its
symptoms. It is to be presumed, therefore, that corresponding
changes taking place within an artery are referable to the same
cause. That the morbid depositions in the artery should not be
exactly identical with those found in other membranes, is to be
anticipated on principles of general anatomy; for the effused
matter, which is the basis of every accidental production, differs in
aspect and nature according to the tissue in which it occurs.
" Thus," as remarked by Bertin and Bouillaud, " serous mem-
branes secrete a coagulable matter prone to transform itself into
cellular or serous layers ; the periosteum furnishes another matter,
which concretes, hardens, and ossifies; the arterial tissue, composed
essentially of a fibrous membrane, exhales a liquid which hardens,
condenses, and becomes converted into cartilaginous patches, or
calcareous scales."
But, admitting the agency of chronic inflammation as a cause of
morbid alterations in arteries, there is reason to believe that some
of them, particularly the calcareous, may take place independent of
it.1 For they are found in most old people ; they sometimes occur
in various detached points very remote from each other; they often
consist of a simple calcareous scale, or an opake yellow spot, with-
out any morbid state of the surrounding membrane ; and such
alterations almost always take place without affording the slightest
sign, either general or local, of their formation. Now it is scarcely
possible to conceive of an inflammation which manifests no symp-
toms, which is restricted to isolated points often remote from each
other, which leaves none of the ordinary vestiges of inflammation
in the surrounding parts, and which is the most frequent at that
period of life when phlogistic action is the least prevalent. We are
brought, then, to inquire what is the cause of morbid depositions
when they do not appear to be referable to inflammation.
Here it is necessary to proceed with caution, as the ground is
purely speculative. Laennec, indeed, thinks it the most simple
and philosophical to acknowledge that we know not the nature of
the derangement of the economy which produces an ossification or
a cancer, but that very certainly it is not the same as that which
produces pus — as inflammation (De PAuscult. torn. ii. p. 684). If
we are not satisfied to remain in this circumspect uncertainty, we
can perhaps scarcely venture farther, in the actual state of our
knowledge, than to suppose that morbid productions are sometimes
results of a depraved action of the vessels, not identical with, or
not amounting to inflammation — a doctrine, indeed, which rests on
the basis of sound observation, and which has been extensively
received since the accurate researches of the present century have
bred a "philosophic doubt" on the tenet of t-he ancients, that all
1 The whole of this argument stands as in the original edition. The
reader still sees that I have not, as M. Bouillaud avers, denied the interven-
tion of inflammation.
CHRONIC ARTERITIS. 227
accidental productions are the effects of inflammation. Admitting
a depraved action of the vessels, it is rational to suppose that, like
inflammation, it would derive its particular character from the
tissue which it affects: hence, that the fibrous and cellular tissues
of the arteries might degenerate into cartilage, bone, &c. — the
changes to which those tissues are prone under the influence of
inflammation.1
But what is it that calls this depraved action into activity? It
appears to me that over-distention of the arteries and their valves
by the force of the circulation is what, principally at least, pro-
duces the effect. To this opinion I am led by the following con-
siderations: 1. That it is very uncommon to see considerable
hypertrophy with dilatation of the heart unattended by fibrous
thickening of the mitral valve and its tendinous chords, though
1 I have the satisfaction of finding an identical train of reasoning in the
Path. Anat. of Andral, though I had not seen his work when the above was
written in 1831. After showing that, from the embryo to extreme old age,
the fibrous and still more the cartilaginous tissues, present a constant ten-
dency to ossification ; that, in old age, ossification acquires a new disposition
to seize on other parts of the fibrous and cartilaginous tissues; and that
"irritation or increased vascular action'''' generally precedes osseous trans-
formation when taking place at a premature period, or in parts where it does
not usually occur in the progress of life, he proceeds: — "But in a variety of
other cases, no morbid action whatever can be discovered previously to the
deposition of osseous matter. How often, for example, do we find these
depositions in the middle coat of arteries, in the fibrous tissues situated at
the different orifices of the heart, in the duia mater, the pericardium, the
capsule of the spleen, &c., without our ever having had the slightest evi-
dence of the existence of any antecedent irritation of the part, either from
the examination of symptoms during life, or of the morbid appearances
found after death. No doubt, it may be argued that the irritation might
have existed in a latent form; but before I can adopt such an hypothesis, it
must first be clearly and satisfactorily proved that this irritation is an
essential element in the production of ossification; in which case I must of
necessity admit its existence, for then, the effect being produced, its cause
must have existed either in a manifest or latent form. In my opinion, how-
ever, we have no more ground for admitting an increase of vitality as the
cause of the osseous, than of the fibrous or cartilaginous transformation.
We learn from observation that the nutrition of the part is perverted, and
altered from its natural type, but neither theory nor observation shows any
necessary connection between this alteration and the exaltation of the vas-
cular action of the part" (Vol. i. p. 370).
In the passage of the above quotation in italics, M. Andral, no less fairly
than logically, throws the onus probandi on INI. Bouillaud, and furnishes a
complete reply to the following favourite argument of that author. " The
first difficulty to be resolved was, to show by accurate cases that old men,
affected with ossification, had not experienced any chronic, obscure, latent
inflammation in the parts where the accidental productions were seated.
But I declare that I have not found in any author the solution of this first
and very grave difficulty I think, in fine, that amongst the ftssifications
of the heart and arteries in old men, some have certainly been preceded by
an inflammatory process, as in young subjects. But I declare that I do not
yet possess all the necessary proofs to be convinced that there are others, in
the production of which that process has positively not played any species
of part. Let us wait." (Traite, vol. ii. 308.)
15*
228 HOPE ON DISEASES OF THE HEART.
the valve be otherwise sound and efficient, and though no signs of
inflammation had preceded : 2. That (according to an observation
of Bo'erhaave, related by Morgagni) arterial ossifications are found
in stags long and often exercised in running, and not in those
which lead a tranquil life in the parks of the great: 3. That dis-
eases of arteries and aneurism are more common, in the proportion
of at least seven or eight to one, in men than in women, the life of
the former being much more laborious, and the circulation more
liable to excitement from potation of vinous or spirituous liquors,
&c. : 4. That ossifications, &c. occur in those arteries, more espe-
cially, which are most exposed to over-distention ; namely, the
arch of the aorta, which immediately sustains the whole brunt of
the left ventricular contraction, and the arteries of the brain, which,
not having the support of a cellular sheath, and being bedded in a
soft, pulpy substance, are weaker than any others : 5. That the
arteries of the brain are more apt to become ossified when there is
disease of the heart increasing the pressure upon them, either by
increased afflux, as in hypertrophy, or diminished efflux from
venous retardation, as in dilatation or valvular obstruction : 6.
That arterial ossifications are more especially incident to the aged,
in whom the arterial and all other tissues sustain a diminution of
elasticity and cohesiveness in consequence of the diminished vascu-
larity which characterises old age. Perhaps the same reason, viz.
over-distention, may be assigned for the remarkable frequency of
the arterial depositions in those who have suffered much from
syphilis or mercury; for as these maladies induce a cachectic state,
which lessens the elasticity of all the tissues, the arterial tissue
would, under these circumstances, suffer proportionably more from
the distending pressure of the circulation. To the above catalogue
we may perhaps add gout, (an affection which is remarkably often
attended with ossifications ;) for, in this disease, there is not only a
morbid condition of the general system, evinced by the deposition
of gouty concretions in the fibrous structures; but there is also, in
general, a morbid degree of plethora, and therefore a greater than
ordinary prevalence of vascular tension.
I might now corroborate the preceding argument respecting the
occurrence of ossifications, (fee, independent of inflammation, by
referring to the laws of analogous transformations, and showing
that transformation of cellular tissue to fibrous, of fibrous to car-
tilaginous, and of cartilaginous to osseous, are frequent and common
results of tension, friction, or increased exercise of the natural func-
tion of a part, wholly independent of inflammation. But I leave
M. Bouillaud to do this for me, because, in the following admis-
sions, where this distinguished author now qualifies his original
opinions, -which disclaimed any agency but inflammation, the
reader will distinctly discern a recognition of my own argument.
" It appears to me probable," says he, " that the perpetual friction
to which the valves and arterial walls are subjected, is really a
physiological or functional condition which ought not to be over-
CHRONIC ARTERITIS. 229
looked, in determining all the circumstances calculated to favour
the development of certain indurations of these parts, whether
cartilaginous, or osseous. No physician is ignorant that habitual
pressure and friction on other parts, eventually entail various kinds
of induration. Who knows not, amongst others, the horny excres-
cences (corns) produced on the toes by the pressure and friction of
tight shoes? Who knows not the callosities of the hands in persons
devoted to the most fatiguing manual occupations? Who knows
not, finally, that tendinous and fibrous tissues, subjected to long
and violent friction, not unfrequently ossify? Assuredly, it is not
I who will deny the intervention of such causes (Traite, ii. p. 309).
In admitting that these structural changes may occur indepen-
dent of inflammation, M. Bouillaud admits as much as 1 have ever
contended for in this volume, as much as Andral contends for;
and as much as, in my opinion, completely cancels his own
declaration at the conclusion of the preceding note.
The whole subject may be thus summed up. Organic diseases
of the interior of the heart and arteries are, in general, results of
inflammation ; but it has not been proved that inflammation is, in
all cases, an essential element in their production ; and there are
the strongest analogical reasons for believing that in some cases
they occur independent of it.
Of the symptoms and treatment of chronic arteritis it is sufficient
to say that, though it in all probability deteriorates the general
health, it presents no distinctly appreciable signs biU those of the
structural alterations — the depositions, dilatations, and valvular
obstructions, to which it gives rise. These signs are treated of
under the heads of aneurism of the aorta and valvular disease.
PART III.
ORGANIC AFFECTIONS OF THE HEART AND GREAT
YESSELS.
This part will comprise the organic diseases, first, of the muscu-
lar substance; secondly, of the pericardium ; thirdly, of the internal
membrane and valves; and fourthly, of the aorta. Adhesion of
the pericardium has been noticed in Part II. for reasons there
assigned. (See p. 196.)
CHAPTER I.
HYPERTROPHY OF THE HEART.
SECTION I. — Anatomical Characters, with classification and nomenclature of
Hypertrophy.
Hypertrophy is an augmentation of the muscular substance of
the heart, resulting from increased nutrition.
As late as the year 1811, this affection was very imperfectly
understood. No other form of it had been recognised, than that
which was denominated by Corvisart Active Aneurism, (the hyper-
trophy with dilatation of Laennec,) a combination of two distinct
affections which may exist independently of each other. Mor-
gagni,1 Corvisart,2 and Burserius,3 indeed, had each seen and
described hypertrophy without dilatation; but it had not particu-
larly arrested their attention, nor led to any inferences. It was
reserved for M. Bertin in 1811 to throw new light on this subject.
In three memoirs presented to the Academie Royale des Sciences,
he proved that hypertrophy might exist, not only with dilatation,
but also without it; that is, with a natural, and even with a dimi-
nished size of the cavity. Since that epoch, the concurrent ob-
servations of other pathologists, both abroad and in this country,
have confirmed the accuracy of his observations, and led to the
substitution of a new and more definite classification and nomen-
clature, in place of the inaccurate distinctions into Active and
Passive Aneurism introduced by Corvisart.4 .
1 Epist. xvii. art. 21. 2 3d Edit., p. 335. 3 Inst. Med.
4 Baillou and Lancisi were the first who applied the term aneurism to the
heart: Morgagni and Corvisart followed, though they thought the applica-
tion far from being correct. M. Bouillaud, notwithstanding, declares his
HYPERTROPHY OF THE HEART. 231
Hypertrophy presents the following varieties : —
1. Simple Hypertrophy, in which the walls are thickened, the
cavity retaining its natural dimensions.
2. Hypertrophy with Dilatation. This, (the eccentric or aneu-
rysmal hypertrophy of Berth),) presents two varieties : viz : —
a. — With the walls thickened, and the cavity dilated.
b. — With the walls of natural thickness, and the cavity dilated:
i. e. hypertrophy by increased extent of the walls.
3. Hypertrophy with Contraction. In this, (the concentric
hypertrophy of Berlin,) the walls are thickened, and the cavity is
diminished.
This classification is no less convenient than conformable to
nature. The form b. of the second variety was not known to
Laennec, though it was to Bertin. That it really consists of an
augmentation of muscular substance, and therefore constitutes
hypertrophy, is too manifest to require comment; but a further
proof than mere structure is, that it sometimes produces the symp-
toms of hypertrophy, — a fact which the writer ascertained and
made known in 1824, before he had any knowledge that M. Bertin
had done the same.1
The terms " eccentric or aneurismal" and " concentric" are not
so simple and expressive as hypertrophy with dilatation intro-
duced by Laennec, and its natural converse hypertrophy with con-
traction. There is a further objection to the nomenclature of
Bertin. His first variety of dilatation, though identical in its nature
with his second variety of hypertrophy, is designated by a totally
different name, viz. active aneurism (Bertin, p. 376); which could
scarcely fail to lead the inexperienced student into the erroneous
idea, that there was a difference in the nature of the two affections.
Now the only difference consists in degree — in a predominance
of the hypertrophy over the coexistent dilatation, or the converse.
The terms, therefore, should be such as distinctly to imply identity
in nature, and difference in degree only; and this is done in the
simplest manner by giving precedence to the word hypertrophy, or
dilatation, according as the one affection or the other predominates.
Thus, hypertrophy with dilatation denotes a predominance of
hypertrophy, while the converse dilatation with hypertrophy (vid.
Dilatation) denotes a predominance of dilatation. Hypertrophy by
increased extent, (without altered thickness,) of the icalls, (the form
b. of the second variety,) is thus designated when it is accompanied
witli the symptoms of hypertrophy, which I have observed to be
adhesion to it (Traite, ii. 524). In my opinion, it is inadmissible, as it is to
dilatation, and not to aneurism, (in the ordinary acceptation of the terms,)
that an enlarged heart presents an analogy. But when a heart offers a
local or limited pouch or sac, the analogy is to aneurism, and I reserve the
term for these cases.
1 Vid. an Essay by the writer in 1824, read to the Royal Med. Soc Ed.
The Treatise of MM. Bertin and Bouillaud was published in the same
year.
232 HOPE ON DISEASES OF THE HEART.
generally the case when the patient is youthful and robust, and the
disease has not made great advances; but it is called simple dilata-
tion when the symptoms are those of dilatation, which is the case
in aged or enfeebled subjects, or when the disease has made great
advances.
I have thought it necessary to speak thus particularly on the
subject of nomenclature, as, up to the present moment, it has
created much confusion, and must continue to do so until the
terms active and passive aneurism are forgotten.
Natural Dimensions and Weight of the Heart. — Before de-
scribing the anatomical characters of hypertrophy of the heart, it
is necessary to give the reader an idea of the natural dimensions
of this organ. Unfortunately, it is impossible to determine these
positively; for, as they vary according to age, sex, and other cir-
cumstances, there is no immutable standard of comparison which
might serve as a criterion. It is only by the eye, therefore, (and
an experienced eye is necessary for the purpose,) assisted by ap-
proximative weights and measures, that it can be determined
whether the proportion of the heart to the system, and of its several
parts to each other, are natural. I shall first give the proportions
according to Laennec, then subjoin the weights and measurements
more recently made by M. Bouillaud, and finally add the still more
recent results of Dr. Clendinning, my successor as physician to the
St. Marylebone Infirmary.
The proportions assigned by Laennec approach perhaps as near
the truth as it is possible to arrive. They are as follows: "The
heart, comprising the auricles, ought to have a size equal to, a little
less, or a very little larger than, the fist of the subject. The walls
of the left ventricle ought to have a thickness a little more than
double that of the walls of the right : they ought not to collapse
when an incision is made into the cavity. The right ventricle, a
little larger than the left, and having larger columnse carneas not-
withstanding the inferior thickness of its walls, ought to collapse
after an incision has been made into it. Reason indicates, and
observation proves, that, in a sound and well-built subject, the four
cavities of the heart are, within very little, equal to each other.
But as the walls of the auricles are very thin, and those of the
ventricles have much thickness, it results that the auricles form
scarcely a third of the total volume of the organ, or the half of that
of the ventricles." In the foetus and very young children, the
thickness of the left ventricle does not exceed that of the right to
the extent described.
The right cavities are rather larger than the left, and this is not
owing to sanguineous distention attendant on dissolution: for the
disparity is found, though in a less degree, in animals destroyed by
hemorrhage.
The weights and measurements of M. Bouillaud have not, as
this able observer frankly avows, been made on a sufficient number
of subjects to warrant implicit confidence in the results; but they
HYPERTROPHY OF THE HEART. 233
may be referred to with advantage while we wait for corrections
from more extended observations. They are as follows: —
" In an adult of a medium height and well built, the mean
weight of the heart is from 8 to 9 ounces ; the mean circumference
of the organ, at its base, is from 8 to 9 inches ; the mean longi-
tudinal and transverse diameters are 3i inches ; (the transverse
diameter, in general, rather exceeds the longitudinal ;) the mean
antero-posterior diameter is about two inches.
The mean thickness of the walls of the left ventricle, at the base,
is from 6 to 7 lines.
The mean thickness of the walls of the right ventricle, at the
base, is 2~h lines.
The mean thickness of the walls of the left auricle is 1£ lines.
The mean thickness of the walls of the right auricle is 1 line.
The ventricular cavity, on an average, will contain a hen's
ecr^, but the cavity of the right ventricle a little exceeds that of
the left."
Dr. Clendinning favoured me, at my request, with the following
summary of his researches :
"M. Bouillaud's results seem to me to need rectification. The
oldest subject of his first series, or that of health, appears to have
been but 45 years ; 8 of the 20 were 21 years and under: 3 were
females. So that his healthy average can only apply to the period
between 10 and 45, or, excluding females, 16 and 38. Now, if
the heart increases with years, and, in the male, up to extreme
age, and if disease of the heart be pre-eminently a disease of
advanced years, it seems clear that Bouillaud's standard (8 to 9
ounces) will not serve for subjects mature or declining. I have
attempted to obtain averages accommodated to the advancing
development of the organ, of which a summary account is given
in the Brit. Med. Almanac for 1838, p. 126.
Average weight of the Heart.
Males. Females.
15 to 30 8^ oz 8| oz.
30 to 50 8h oz Sh oz.
50 to 70 9| oz 8 oz.
70 and upwards . . 9f oz 8 oz.
Bonillaud has no measurements of bulk or specific weight : — I,
none of linear dimensions, for reasons stated in my Croonian Lec-
tures."
["The normal heart may be assumed to average for the whole life, above
puberty, about 9 oz. in absolute weight, and Si oz. in bulk, for the male;
and 8 oz. or a little more in weight, and 74 oz. or a little more in bulk for
the female; and to bear after death to the person, for the male, the rate of
about 1 to 160, and for the female, of 1 to 150."— (Clendinning, Croonian
Lectures for 1838.)
The field of research of Dr. C. has been very ample, and the above state-
ment was made after examining and weighing nearly four hundred hearts.
-P.]
234 HOPE ON DISEASES OF THE HEART.
[M. Bizot, of Geneva, a gentleman singularly conscientious and exact in
every thing pertaining to the science of medicine, has published in the
u Mernoires. de la Soeiete Medieale d'Observation de Paris," for 1837, the
result of his researches to ascertain the dimensions of the heart and arteries.
These observations were made in the H6pital de la Pi tie and in the children's
hospital of Paris during the years 1832-33. The subjects of the observa-
tions were 122 individuals above the age of 15 years, (61 males and 61 fe-
males) and 35 children of the two sexes under 15 years old ; making the
whole number 157.
As these observations may probably be the foundation for similar investi-
gations, it is proper that the manner in which he conducted them should be
mentioned in some detail. His words explanatory of this are therefore
quoted. " During the life of the patients, I examined them with great care,
in order to ascertain whether any abnormal signs of the heart or circulatory
apparatus existed j and after death, at the autopsy, all the internal organs
were examined in detail, in order to ascertain positively the organic lesions
which had caused death. After this, the heart and principal arteries were
carefully removed from the body and examined.
At every autopsy, when these parts were measured, I considered them as
presenting data to resolve a new problem, forgetting the former measure-
ments, and resolved to measure and describe minutely, only, what was then
before me. In conformity with this plan, the measurements of each case
were thus collected ; and then, for the first time, the analysis was made upon
the whole number, in order to ascertain with rigorous exactness the average
or medium dimensions. As regards the heart, I first measured it, previous
to its being opened, around its base near the junction of the ventricles and
auricles; after this I took its length, represented by a line passing from the
apex, and falling perpendicularly upon its base; in a similar manner the
greatest thickness was ascertained ; the left ventricle of the heart was then
laid open by an incision passing from the apex along the septum to the aortic
orifice; and for the purpose of exposing its entire internal surface the auii-
culo-ventricular orifice was cut through. The length of the line passing
from the summit of the convex and adherent borders of the sigmoid valves,
and terminating at the two cut surfaces of the walls of the ventricle, indi-
cated the circumference of the base of the left ventricular cavity, and a
second line starting from the point or summit of this cavity, and falling at
right angles upon the first, measured the height of it. I afterwards upon
the incision last mentioned, measured the thickness of the ventricular wall,
perpendicular to the tangent, at three different points, viz : —
First. Near the base, at about six lines from the origin of the muscular
fibres.
Second. At the point of the greatest thickness, which is near the union of
the lower third with the upper two thirds.
Third. At, say, four lines above the point of the heart. The inter-ven-
tricular septum was measured at corresponding points ; and the thickness of
the columnar carnese were always carefully excluded.
In order to measure with facility and uniformity the dimensions of the
right ventricle, I adopted a plan a little different. A longitudinal incision was
made through the posterior parietes from the base to the apex along the
inter-ventricular septum; this, together with a similar incision in front from
the pulmonary artery to ihe apex, separated the ventricle into two portions.
The measurements were taken in the same manner as those of the left ven-
tricle, using great care that no inaccuracies should occur from false measure-
ments, and excluding from the measure the extent* of the orifices of the
pulmonary artery, and that of the tricuspid valve. As regards the thickness
of the parietes, the measures were taken on the anterior incision, and at cor-
responding points with those of the left ventricle.
The very irregular form of the auricles requires for the appreciation of
their cavities, a special preparation of the veins which empty into them, but
HYPERTROPHY OF THE HEART.
235
which I have not been able to do, and this hiatus requires attention in future
investigations. * * * * *
This task has not been done hastily or carelessly; I have devoted to it
almost the whole of my time, whilst making the investigation. In fact, I
have been obliged to do so, for the numerical system when applied to the
study of medicine, presents at the same time, both the imposing authority,
and all the danger of statistics. Properly employed, it establishes incontes-
tible truths; but when indiscreetly used, it may propagate, under the appear-
ance of rigid demonstration, the most unfortunate errors. It is therefore the
duty of a physician in using this system, to be entirely sure that he is work-
ing upon perfectly solid bases, or else, it would be wise that he should not
employ it.
It will be seen in the following tables, that the observations are separated
into two series, men and women, and each into six groups from 1 10 79
years in the males, and from 1 to 89 in the females. In each group the
medium measure for each point of the organ has been presented, and has
been placed according to the age, &c.
Dimensions of the Heart at Different Ages.
The age, as may be seen in the following table, has an important influ-
ence in both sexes upon the size of the heart. This organ increases, not
only in infancy and youth, but also at the subsequent periods of life. This
increase as regards the length and breadth of the organ, is constantly pro-
gressive in the male and female, but it is irregular as regards the thickness,
especially in the female. Thus, the medium thickness of the heart of the
female, in the series from 16 to 29 years, is 17 5-7 lines; it is only 16 2-19
lines in the series from 50 to 89 years; but this is an exception to the gene-
ral rule.
Until the age of 29 years, the increase of the size of the heart is more
rapid than in the subsequent periods of life ; it is, however, less from 10 to
15 years, than from 5 to 9, and from 16 to 29 : this difference is the same in
both sexes. Thus we see from this first table, that it is impossible to have
an uniform type for the volume of the heart in its normal condition ; further,
it shows us a law, which I think has not been heretofore demonstrated ; that
of the indefinite growth of the heart in cases where there have not existed
any functional symptoms of deranged action of that organ.
Table I.
[The measures here given, and those throughout the researches of M.
Bizotf aTe those of the French foot, {Pied de Roi.) I have preferred pre-
senting them as originally given, rather than incur the risk of errors in cal-
culation by converting them into the English equivalent. It may, however,
be recollected, that the Pied de Hoi is equal to 12.7S93 English inches:—
hence by adding 1-15 to the French measure, we obtain a close approxima-
tion to the English measure.]
MALES.
FEMALES.
\°
01
l
13
cr.
w
o
<
Years.
II
"to
o
Lines.
o
o
c
5 ■
to
c
o
13
o
M
C
1c
Eh
Lines.
1 to 4
7
22i
27
10|
! (C ((
8
22 1
25*
101
5 to 9
3
311
33
121
i K it
10
26^
29
n/o
10 to 15
3
34
37
14
a a
5
29f
31 1
12|
16 to 29 18
42t\
45H
ITVo
1 a t(
14
384
42-9-
171
30 to 49 23
50 to 791 19
45H
52H
18fV
50 to 89
27
19
A1A
142^
440-V
46li
16TV
236
HOPE ON DISEASES OF THE HEART.
Dimensions of the Heart in the two Sexes.
Sex,,as may be seen in the preceding table, has a marked influence upon
the size of the heart. Under all circumstances the size of the female heart
is found to be less than that of the male. The influence of sex is such, that
among women in the last of the series of advanced age, (see table,) which,
although it embraces individuals older than that of the last series of men,
yet the smaller volume of the heart is still shown in a marked manner.
Thus then, the law of the influence of sex is as positive as that of age ;
and as regards the last, it may be remarked that its persistence in the two
sexes, studied separately, and as two distinct groups, is a confirmation of its
truth. * * * *
# * * * * * *
The heart, unlike the muscles of animal life, unlike the greater part of
the other organs, which become atrophied with age, continues to grow and
increase. * * * * *
* * * # . * * *
Old age in the two sexes, is the epoch in which the heart has the largest
volume. It is, positively speaking, not only more voluminous at that period,
but it is absolutely greater in relation to the size of the body generally, if it
be true that the body withers and diminishes, as it is said, in the last period
of life.
Dimensions of the Heart relatively to the Height of Persons over Sixteen
Years of Age.
The dimensions of the heart, as indicated in the second table, does not
appear to vary very greatly with the height of the person. There is, how-
ever, a slight difference; and what is surprising, is, that amongst men as
well as amongst women, the absolute volume of the heart is rather less in
tall than in short persons; thus in men whose height was over sixty inches,
(French) 5 feet 3 95-100 inch English, and in females whose height was
over fifty-five inches, (4 feet 10 61-100 in English,) the medium of the
dimensions of the heart, and principally that of the breadth of the organ, is
less than amongst shorter individuals.
The result of investigation here, like that in many other cases, is contrary
to the ideas which we should have formed a priori. It will be seen that a
better standard of comparison exists between the width of the shoulders and
the volume of the heart.
Table II.
MALES.
Height of 60 inches, French, (5 feet
3^- in., E.) and under. (30 cases.)
Length,
lines.
Medium 43^-
Breadth.
52
Thickness.
17_7_
1 ' 25
Height of 60 inches and over. (30
cases.)
Length,
lines.
Medium 43T|T
Breadth.
4RJL
Thickness.
17 2
14 SI
Height of 55 inches French (4 feet
10T6J_ in., E.) and under. (18 cases.)
Length.] Breadth,
lines.
Medium 41-
46*
Thickness.
is*
Height of 55 inches and over. (34
cases.)
Length,
lines.
Medium 4W*
Breadth. I Thickness.
43§* I 15TV
Dimensions of the Heart relatively to the Width of the Shoulders.
Table No. 3 shows, that in each sex the average measurements of the
heart are greater in proportion as the width or breadth of the shoulders in-
HYPERTROPHY OF THE HEART.
237
creases; there is but one exception to this, which occurs in the female in
relation to the measure of thickness.
Table III.
MALES.
Width of 13 inches French, (13 in.
10^ lines E.) and under.
Length. I Breadth. I Thickness.
Medium 44£|
471?.
^ ' 2 3
18*t
Width of 13 inches and over.
Medium 45ft | 56ft | 17}
FEMALES.
Width of 13 inches French, (13 in.
10_2_ lines E.) and under.
Length.! Breadth. I Thickness.
Medium 39
44-1-
17*
Width of 13 inches and over.
Medium 42,
451*
14_2
DIMENSIONS OF THE VENTRICLES.
Dimensions of the Ventricles at different Ages.
Table No. 4 shows, that in both sexes, from birth to the most advanced
age, the capacity of both the right and left ventricles has a constant tendency
to increase. It is true, that their dimensions do not increase in a regular
manner at the different periods of life, but that the internal capacity is most
rapidly developed during youth, and that after fifty years of age it is ex-
tremely slow; bur, notwithstanding, it is constantly taking place.
It is also seen that the right and left ventricles have greater breadth1 than
length in both sexes and at all ages. And, finally, that the right ventricle is
proven to have greater breadth and length than the left, and that the relative
capacity of the two ventricles are nearly the same in all ages : thus, for ex-
ample, in the male, the average breadth (or circumference) of the left ven-
tricle being 31 lines (33.03 lines English.) from one to four years of age,
and about 51 lines (54.35 English,) from 16 to 29 years, that of the right
ventricle, which was about 48 lines (51.16 English,) from 1 to 4 years, has
augmented in the same proportion, and from 16 to 29 years, is found to be
79 lines and a fraction (84.2 lines E.): from 50 to 79 years the internal cir-
cumference of the left ventricle being 56| lines, (60.7 lines E.) that of the
right is 87 lines (92.7 lines E). Hence it is seen, that the proportions of
the relative capacity of the ventricles in all ages are relatively the same.
Table IV.
Left Ventricle.
MALES.
Ages.
1 to 4
Lines.
Length. Breadth.
20 31
FEMALES.
Length.
18J- lines.
Breadth.
29f
5 to 9
231 351
22}
33J
10 to 15
27§ 42
231
36f
16 to 29
33|f 51ft
29ft
4VT
80 to 49
50 to 79
36 56}
31fg
31
46TV
49i
Medium from 15 to 79
34fT 54ft
15 to 89
*1*
48f#
The word breadth is here used by M. Bizot as synonymous with circumference.
238
HOPE ON DISEASES OF THE HEART.
Right Ventricle,
Ages.
1 to 4
Lines.
Length. Breadth.
201 47|
Length.
181 lines.
Breadth.
441
5 to 9
24 54
221
491
10 to 15
29 63
24|
54
16 to 29
36-L| 79^.
35
74A
30 to 49
50 to 79
87H 83J|
37i 87
50 to C9
76i?
76
Medium from 15 to 79
37M 82i±
From 15 to 89
34
76|
Dimensions of the Ventricles in Reference to the Sexes.
The medium measures, generally, in reference to every series of ages, as
indicated in the preceding table, shows that the dimensions of the ventricles
in particular, as well as the general dimensions of the heart, are less in the
female than in the male sex. * * * *
********
OF THE THICKNESS OF THE PARIETES OF THE VENTRICLES.
Thickness of the Wall of the Left Ventricle.
The parietes of the ventricles vary in thickness. A longitudinal section
of the wall of the left ventricle is somewhat fusiform; its greatest thickness
being near the base and diminishing towards the apex.
The following table, No. 5, also shows us that the thickness of the walls
of the left ventricle increases in both sexes, not only during the early periods
of life, but also in middle and advanced age: but although the increase is
slower from 50 to 89 years, than during the anterior portion of life, that it
exists is very evident.
'
table V.
MALES.
females.
Lines.
Lines.
Ages.
Base.
Middle
Apex.
Base.
Middle.
Apex.
1 to 4
3
2-9-
10
ItV
^ 16
21
2TV
5 to 9
H
H
2|
h'o
3tV
h\
10 to 15
3|
H
n
3 A
3|
3}
16 to 29
4|
n
n
4f
4-7-
^1 3
3iV
30 to 49
411
^4 6
*A
31 3
°2 3
4*
321
°54
3/t
50 to 79
A37
^3 8
m
^2 9
50 to 89
4*
5
3f
Med'mfrom 16 to 79
4_6 5
^122
Sta-
°122
16 to 89
H
H
m
From the preceding table it is seen that the thickness of the parietes of
the left ventricle is less in the females than in the males, and this exists in
all ages, with the exception of infancy from one to four years, when the
female heart is slightly thicker at the apex than that of the male. It is further
proved that this thickening increases constantly as age advances. This
result is directly contrary to the opinion of M. Beclard,1 who thought that in
old age the heart became thinner and thinner.
The thickness of the inter-ventricular septum follows the same modifica-
tions of that of the wall of the left ventricle, and is influenced by age, sex,
&c, as previously detailed. This will be seen by examining the following
table.
Dictionaire de Medec. nouvel. edit., t. 8., page 181.
HYPERTROPHY OF THE HEART.
239
Thickness of the Inter-ventricular Septum in its middle portion.
Table VI.
FEMALES.
Thickness of the middle part
2| lines.
3i
8f
m
m
5 A
MALES.
Ages.
Thickness of the middle part.
1 to 4
3-^ lines.
5 to 9
4
10 to 15
41-
16 to 29
4-i-i
30 to 49
43.1
^2 3
50 to 79
5*
EIGHT VENTRICLE.
The greatest thickness of the walls of the right ventricle is near the base of
the heart. Contrary to what we have seen in the parietes of the left ventricle,
the thickness increases very slightly with age, and remains very nearly sta-
tionary.
Table VII.
Right
Ventricle.
I
Ages.
1 to 4
5 to 9
10 to 15
16 to 29
30 to 49
50 to 79
Base.
9
1 0
1 j_
1 3
•4
"if
139
A4 "6*
2->-
Middle.
_6_
1 0
5.
6
1*
A
Apex.
TV
5
6
£
6
w>
4 5
4 8
8.1
8 4
FEMALES.
Base.
Middle.
Apex.
'tV
7
8
1 3
24
»ft
1
7
1 0
i*
1t3o
A
1 4
If
2 5
'28
l£f
1«
25
27
1*
H
1
«l
»*
G73
7 2 0
Med'mfrom 16 lo79
J.1 3
122
i24 4
15 to 59
If the average thickness of the parietes of the right ventricle from 16 to
89 years of age, (which is allowable, inasmuch as it varies so little with
age,) be compared with the average or medium thickness of the parietes of
the left ventricle in each series of age, we arrive at the two following tables.
Tables VIII and IX.
MALES.
Left Ventiicle.
Right (2ft
ventricle. | 3f
j »*
Medium ! 4£
lines.
112.
1 22
'sfr
Ages.
1 to 4
5 to 9
10 to 15
16 to 29
30 to 49
50 to 79
FEMALES.
Left Ventricle.
Right ( 2f lines,
ventricle. | 3T\,
I Q2
J *J
Medium ] 4Tv
* 1 3
IF
It results from these two tables, that to take the thickness of the wall of
the right ventricle as a term of comparison, as has been generally done, in
order to estimate the proportional thickness of the parietes of the left ventri-
cle, is the most defective means possible, inasmuch as the right ventricle
remains stationary, whilst the left constantly increases. Thus, the nearer
we approach the first moments of life, the two ventricles resemble each other
more nearly as regards their thickness ; at birth the left is rather thicker, but
in the foetus, the thickness of the two ventricles is nearly the same.
240 HOPE ON DISEASES OF THE HEART.
These results do not accord with the views of Piofessor Andral,1 who
thinks, that in infancy the thickness of the parietes of the left ventricle bears
the rano to that of the right as three or four to one. This proportion is
nearly correct as respects extreme age, but is not so in early life. Finally,
the thickness of four to five lines, beyond which Professor Cruveilhier con-
siders the hypertrophy of the right parietes as commencing, are in fact evi-
dences of considerable hypertrophy, since in the male of 50 to 79 years the
maximum thickness of the right ventricle is only 2 1-9 lines, and in the fe-
male 1 1-4 lines in the normal state ; hence when the measurement of the
right ventricle in man is 3 lines in thickness, we may regard it as a com-
mencing hypertrophy, and 2 1-2 lines in the female would show it as already
formed. — P.]
Anatomical Characters of Hypertrophy. — The muscular sub-
stance in hypertrophy is usually firmer and redder than natural.
These characters, however, are not essential to the disease ; for,
in aged, or exhausted, anaemic subjects, the opposites are often
observed ; namely, flabbiness with paleness, — the states which
prevail in the universal muscular system. When firmness exists
in a great degree, it constitutes Induration^ a distinct affection,
dependent, not on increased, but on altered nutrition of the part,
the elementary particles being denser than natural. It is generally
attended with hypertrophy.
[The muscular tissue of the heart becomes not only augmented in the
hypertrophy of that organ, but it is also subject to various changes in its
structure, according to the different phases of constitution and the various
states which may exist in the character of the blood. In persons whose
general health is vigorous, whose blood is rich, in whom nutrition is active,
the cardiac muscular structure in hypertrophy becomes redder and firmer
than usual. In the leucophlegmaiic, in the cachetic, &c, the muscular fibre
is relaxed, flabby, softened, and is then always associated with dilatation.
"In cases of organic disease of long standing," (says Williams) "espe-
cially with close adhesion to the pericardium, I have repeatedly seen threads
or laminae of a dirty white tissue among the muscular fibres, many of these
fibres having also partially lost their colour, and the others being in a flabby
state." Sometimes the enlargement of the heart is due to a structure con-
taining much fat, analogous to that often seen in the pelvis of the kidneys : —
in other cases, though rare, the whole of the ventricular parietes have been
transformed into dense fibrous tissue.
Such abnormal changes as those last mentioned, must have an important
influence on the functions of the heart: — an influence essentially different
from mere muscular enlargement. Yet, all the forms of hypertrophy may
originate from inordinate action of the heart, modified by the special charac-
ter of the "nutrient fluid" which may circulate through it.— P.]
Hypertrophy may either be confined to a single cavity, or may
simultaneously affect several, or even the whole. Sometimes one
cavity is thickened, whilst another is attenuated. The full con-
sideration of this subject comes under the head of exciting causes,
as it is principally by these, that the nature and extent of the affec-
tion is determined. It may here suffice to remark, generally, that
the ventricles are more obnoxious to the disease than the auricles,
because they are exposed to a greater variety of exciting causes,
1 Anat. Path. torn. ii. page 283.
ANATOMICAL CHARACTERS OF HYPERTROPHY. 241
and because the auricles are remarkably protected by the auriculo-
ventricular valves.
When all the cavities are hypertrophous and at the same time
dilated, the heart attains a volume, two, three, and occasionally
even four times greater than natural ; and its weight, properly
8 or 9 ounces, may be thrice as much (Bouillaud's weights). A
case lately occurred at St. George's, in which it was two pounds
and a half. The form of the organ, instead of being oblong, is
then spherical, or even much broader than long, its apex is scarcely
distinguishable, and, as the diaphragm does not retire sufficiently
to yield space downwards for the enlarged organ, it assumes an
unnaturally horizontal position, encroaching so far upon the left
cavity of the chest, as sometimes to force the lung upwards as high
as the level of the fourth rib, or even higher. I lately examined a
subject in which it had been forced much higher. In Bouillaud's
case 53, the base of the heart ascended to the second intercostal
space, and its point reached the eighth ! When great enlargement
is accompanied by adhesion of the pericardium, the organ is secured
by the attachments of the membrane, in a higher situation than
its gravity would otherwise dispose it to assume; and being thus
impacted between the spine and the anterior parietes of the chest,
it is apt to occasion a preternatural prominence of the praecordial
region. I am not aware that this remark has been made by any
other writer, but I have seen the phenomenon in so many instances
that I am disposed to assume it as a general fact. I have also
shown that an increased, double jogging impulse results from the
same cause (see Adhesion of the Pericardium, p. 199).
The left ventricle, being more prone to thickening, and not less
to dilatation than the right, sometimes attains a volume seldom or
never acquired by the right; and when its enlargement is enor-
mous, it occupies not only the left precordial region, but. extends
far under the sternum, where its impulse and sound may be mis-
taken for those of the right ventricle' (Case of Lambert).
The walls of the left ventricle, the natural thickness of which
averages about half an inch in the adult, may be increased to the
extent of one, one and a half, or, according to some, of two inches.
M. Bouillaud's recent measurements place the range of hypertrophy
of this ventricle between 7 and 14 lines. The cases are rare in
which it exceeds an inch and a quarter, or 15 lines (see Figs. 15
and 20). The situation of the greatest thickening is usually a
little above the middle of the ventricle, where the columnar car-
neas are inserted. Thence, the thickness decreases rather suddenly
towards the aortic orifice, and gradually towards the apex, where
it is reduced to less than half. When hypertrophy maintains these
proportions in the different parts of the ventricle, the state is only
an exaggeration of the natural form. The case is different when
the hypertrophy takes place inwards and diminishes the cavity ;
1 Laennec, torn. ii. p. 507.
10— d 16 hope
242 HOPE ON DISEASES OF THE HEART.
for then the whole ventricle is nearly equally thickened, and its
form is unusually globular.
The columnas carneas generally participate in hypertrophy, (Fig.
20,) but sometimes, when there is much dilatation also, they appear
to be stretched, flattened, and attenuated. The inter-ventricular
septum, though belonging almost entirely to the left ventricle, is
commonly less thickened than the external walls. When the left
ventricle is greatly enlarged, the right, if unchanged, is applied, in
a flattened form, to its superior and lateral part, and by contrast
looks singularly small. But if, as generally happens, the right is
elongated, it is, as it were, folded around the left.
(_" The several forms of hypertrophy generally affect chiefly one of the
compartments of the heart, and none so frequently as the left ventricle;
next the right ventricle, and then the auricles. In the latter, dilatation is
almost always combined with the hypertrophy. Dilated hypertrophy is,
in fact, the most common form of the ventricles also. It is by no means
uncommon to see particular parts of a compartment more enlarged than
others. Thus the fleshy pillars of the mitral valve, those of the tri-
cuspid valve, the cross muscular stays and net-work of the interior of the
right ventricle, and the musculi pectinati of the right auricle, are fre-
quently developed to an unusual degree. The increase in the pillars
of the valves is generally associated with some defect of the valve. —
I have occasionally seen the thickening of the walls near the base much
greater than near the apex; probably from the undue development of
the fibres that encircle this part ; rarely the converse is the case. In dilated
hypertrophy of the ventricles there is a considerable difference in the shape
which it assumes in different cases, the most remarkable varieties being
those of elongation and lateral enlargement. Hypertrophy of the left ven-
tricle, with elongated dilatation, is most commonly associated with disease
of the aorta or its valves, especially those which permit regurgitation. In
disease of the mitral valves or orifice, the dilatation is usually more lateral
or globular ; but this form is met with also without valvular disease. In
the right ventricle, also, the enlargement is in some cases more in the pul-
monary, in others more in the inferior or auricular portion of the ventricle;
but I do not know that I can associate these differences with other particular
lesions." — C. J. B. Williams'1 s Lectures on the Chest. — P.]
The cavity of the hypertrophous left ventricle is sometimes
dilated to such a degree as to admit the largest orange or the fist
of an adult (e. g. Bouillaud's cases 132-62). I have twice,during
the last six months, seen it exceed even these dimensions. On
the contrary, in hypertrophy with contraction, the cavity may be
reduced to the size of a small walnut or a pigeon's egg: in Bouil-
laud's case 118, l: it could scarcely contain the finger." These
are the extremes of dilatation and contraction. As the natural
capacity of the left ventricle averages the size of a hen's egg, it
may be regarded as considerably dilated when it equals that of a
goose's egg.
When the right ventricle alone is hypertrophous, it may descend
lower than the left, and constitute the apex of the heart. Its
columnas carneas, naturally more numerous and complicated than
those of the left, are more susceptible of thickening than the walls
themselves of the cavity. Hence, the increased size of the columnse
ANATOMICAL CHARACTERS OF HYPERTROPHY. 243
is commonly the first object that arrests the attention, and to them
alone is the hypertrophy in many instances confined. They are
sometimes so curiously interlaced and attached, as to traverse the
ventricle in every direction, subdivide it into various compartments,
and in some cases, almost totally to fill up its cavity, as in case 89
by Bertin, and that of Collins. These changes never take place
to the same extent in the left ventricle. The total thickness of the
walls of the right ventricle, naturally averaging 2h lines, rarely
exceeds four or five; yet it has been known to attain from eleven
to sixteen, as appears from the SSth case of Bertin, and one, by
Soins, in the Archives de Medicine. In Bouillaud's case 16, it
was 8 to 10 lines, and in case 11 about an inch. In a girl of nine
years old, (see case of Collins, — Cyanosis,) I have met with it
measuring six or seven lines ; which is equal in proportion to
nearly double that extent in the adult. The greatest thickening
of the right ventricle is near its base : lower down, though the
columns carneas be enlarged, their interstices are usually thin, and
not unfrequently translucent.
The cavity of the right ventricle, naturally a little larger than
a hen's egg, may be dilated to the size of a goose's egg or more ;
or it may be contracted to less than a pigeon's egg. In Bouillaud's
case 65, it would scarcely contain the thumb, and in case 123, the
columnas carneas was so thickened and adherent that there was
scarcely any cavity left, and the blood could only filter through the
narrow spaces between them. These small dimensions are gene-
rally in connection with malformations of the heart, and, especially,
the open foramen ovale and contracted pulmonic orifice.
Hypertrophy may not only be confined to a single ventricle,
whether the right or the left, but it may be confined to particular
parts only, as the base, the septum, the apex, the columnar carneas,
or the external walls; the remainder of the cavity being either
natural, or attenuated. Again, a thickened ventricle may be con-
tracted in one part, while it is dilated in another. In examining in
the dead subject mixed cases of these descriptions, it is necessary
to counterpoise the opposite conditions, to balance the hypertrophy
against the tenuation, and the dilatation against the contraction, in
order to determine which is the predominant affection.
The hypertrophy of the auricles is almost invariably of the
second species, or that with dilatation. Laennec even states that
he has never met with any other (Laennec de I'Auscult. torn. ii.
p. 524). The simple and the contracted forms, however, are not
without example. The thickening is diffused in a very uniform
manner throughout the cavities, the musculi pectinati being the
only parts in which it is more considerable than elsewhere; and,
as they are larger and more numerous in the right, than in the left
auricle, it is in the former that hypertrophy proceeds to the
greatest extent. It occasionally renders the auricle nearly as
thick as the right ventricle. This I have never known to take
16*
244 HOPE ON DISEASES OF THE HEART.
place in the left auricle. Sometimes the musculi pectinati are
the only parts in which hypertrophy shows itself. The thicken-
ing of the auricular walls seldom exceeds double the natural
state, (i. e. 1| lines for the left auricle, and 1 for the right.) and,
being even then inconsiderable, it may easily be overlooked by an
inexperienced eye. When it amounts to a quarter of an inch,
which is rarely the case, it is very perceptible.
When hypertrophy has been preceded by pericarditis or endo-
carditis, it is common to find the ordinary vestiges of inflamma-
tion ; namely, adhesion or other changes of the pericardium, and
thickening, with opacity, of the valves and tendinous chords, from
hypertrophy of their fibrous tissue, and its transformation into
steatoma, cartilage, or bone. These valvular changes may also
take place independent of inflammation, as shown at p. 226. So
common, indeed, is the fibrous transformation, that in cases of
great hypertrophy with dilatation, though the valves retain their
natural size and efficiency, they are very rarely exempt from
thickening; as if they required to be strengthened in order to
sustain the augmented force of the ventricle, and as if the in-
crease of action resulting from this force, was in conformity with
a general law, the cause of their hyper-nutrition.
SECTION II. — Mode of Formation with the predisposing and exciting Causes of
Hypertrophy.
Mode of formation and predisposing causes of Hypertrophy. —
I shall first notice this affection as resulting from ordinary causes,
and finally advert to its connexion with inflammation.
Hypertrophy, independent of inflammation, takes place in the
heart by the same process as in any other muscle. Increased
action causes an augmented afflux of blood, and there results a
corresponding increase of nutrition. Diminished action, on the
contrary, has the reverse effect. Thus, the arms of the smith and
the legs of the dancer, are unusually robust ; while limbs para-
lysed or not exercised, are pale and emaciated. If, however, the
circulation can be reinvigorated in the palsied part, nutrition is
increased. An individual within my knowledge, whose arm had,
in consequence of an attack of hemiplegia, been for twenty years
emaciated, contracted, without radial pulse, and immovably fixed
to the side, submitted the limb to the process of vigorous sham-
pooing. In a few months, the pulse returned, the emaciation
sensibly diminished, and the motive power was sa far restored that
the individual could raise the hand above the head.
In the same way, when, from mechanical* obstruction or any
other cause, blood is inordinately accumulated in the heart, the
organ is provoked to extraordinary efforts ; it struggles against
the obstacle ; it frets and labours to overcome it ; the coronary
FORMATION AND CAUSES OF HYPERTROPHY. 245
arteries are excited to increased activity : augmented nutrition
ensues ; the parietes are thickened, the muscular power is in-
creased ; the effects, superadded to the cause, induce a still
greater violence of action ; and, thus, the disease is not only-
established, but has a constant tendency to increase.
The left ventricle is much more prone to hypertrophy than the
right; and the right, again, than the auricles.
This admits of explanation on very simple principles. It is
found that hollow muscles resist over-distention by their contents
with a force exactly proportionate to their strength. Now, as the
act of resistance, by stimulating the arteries to increased action, is
the cause of increased nutrition, it follows that stronger muscles
must be the more susceptible of hypertrophy. Accordingly, on
referring to the heart, we find that the relative structure of its
several compartments is such as to predispose the organ to those
changes which it actually undergoes from over-distention.
The left ventricle, for example, being charged with the immense
burden of the greater circulation, is proportionably substantial and
robust ; the right, having the comparatively light task of propelling
the blood through the minor or pulmonary system, is little more
than one third as thick and powerful as the left : the auricles,
again, having a still less laborious function to perform, have a still
more limited muscular provision.
Hence, it is easily understood how a distending force sufficient
to overcome the contractile and elastic power of the right ventricle,
might merely operate as a stimulus to the superior muscularity of
the left. While the former, therefore, incapable of reacting on its
contents, would dilate; the latter, excited to extraordinary efforts,
would become hypertrophous.
It is not, however, to be supposed, that while the left ventricle
is becoming hypertrophous, it may not, at the same time, undergo
dilatation : nor, on the other hand, that the right ventricle, while
yielding to dilatation, may not become hypertrophous ; for observa-
tion teaches us, that the combination of hypertrophy with dilata-
tion, either in the left ventricle alone, or in the two conjointly, is
the most ordinary form of organic disease of the heart.
For an explanation of the cause why dilatation accompanies
hypertrophy, the reader may refer to the chapter on dilatation.
Why hypertrophy sometimes accompanies dilatation of the right
ventricle, may be here explained, and it admits of an explanation
in one or other of two ways.
1st. It has been remarked by Laennec, (Traite de l'Auscult.
torn. ii. p. 496,) that a large proportion of mankind are born with
ill-proportioned hearts, the parietes being a little too thin, or a
little too thick, on one or both sides. Now, when this unnatural
thickness exists in the right ventricle, it is clear from what has
been said above, that it must impart to that ventricle an increased
disposition to hypertrophy. This explanation, however, is not very
246 HOPE ON DISEASES OF THE HEART.
satisfactory, as the existence of the malformation described by
Laennec cannot be positively proved : yet, as all the other organs
and parts of the body are liable to defects of natural conforma-
tion,— as, in other terms, the all-wise Author of nature, who oper-
ates by natural means, has sown the seeds of mortality in every
part of the system, it is consistent with analogy to suppose that
the heart may be liable to the same.
2dly. As augmented nutrition is excited in the left ventricle by
stimulating it in proportion to its power, so a stimulus bearing the
same proportion to the power of the right ventricle, must have the
same effect on it also. Accordingly, in the majority of cases of
hypertrophy of the right ventricle, an obstacle is found to exist of
such a nature as the one described. The obstacles which I have
most frequently found to produce the effect, are, contraction of the
mitral valve operating in a retrograde direction through the lungs,
and that of the orifice or semi-lunar valves of the pulmonary artery.
These affections being usually slight at their commencement and
slow in their progress, oppose an obstacle to the circulation not
only moderate in degree, but constant in its operation, — the two
circumstances best calculated to induce hypertrophy of the right
ventricle. MM. Bertin and Bouillaud conceive that the greater
tendency of the left ventricle than of the right to hypertrophy,
depends upon the more stimulant quality of the arterial blood cir-
culating through the former. This opinion they found on the cir-
cumstance that hypertrophy of the right ventricle in most cases
accompanies patescence of the foramen ovale, which lesion, they
think, causes an influx of arterial bloodvinto the right ventricle.
But, admitting that arterial blood in the right ventricle does occa-
sion hypertrophy, it does not follow that it should have the same
effect on the left ; for, of the former ventricle it is a morbid stimu-
lus, but of the latter it is the natural one. Accordingly, direct
proof is to be found in the auricles that arterial blood is not the
cause of hypertrophy; for the left auricle, which, on MM. Bertin
and Bouillaud's principle, ought to be more subject to hypertrophy
than the right, is less so. It will be shown, moreover, in the chap-
ter on malformations of the heart, that, in the cases on which these
gentlemen found their opinion, the blood does not enter the right
ventricle.1
1 M. Bouillaud, who drew up the work of Benin, was the author of the
above opinion. In his Treatise in 1835, (vol. ii. p. 456,) he abandons the
idea that the stimulant quality of the arterial blood predisposed the left ven-
tricle to hypertrophy, and he "avows that this cause of irritation or of exci-
tation is a little hypothetical" in reference even to the right; yet he thinks
that die hypertrophy of the right, which usually accompanies a communi-
caiion between the two ventricles, and the hypertrophy of the coats of veins
in cases of varicose aneurism,, are strong considerations militating in favour
of his opinion that the irritation of arterial blood may contribute to occasion
the hypertrophy. It must not, however, be forgotten that, in both the pre-
ceding cases, the weight of the arterial circulation is thrown on the venous
system, and it may be asked whether this alone is not sufficient to account
for the hypertrophy, both of the right ventricle and the veins.
FORMATION AND CAUSES OF HYPERTROPHY. 247
[''Hypertrophy and dilatation, opposite as they seem, often arise from
similar causes, but operating on a different condition and quality of tissue.
When from any cause, whether the quantity or quality of the blood or the
irritability of the fibres, the heart is excited to excessive action for a consi-
derable length of time, and the nutrient function of its vessels is not impaired
by a general cachectic or chlorotic state, like any other highly exercised mus-
cle it increases in substance, it becomes over-nourished or hypertrophied:
and there is, in the case of the heart, an additional reason why increased
action should eventually lead to hypertrophy — namely, the direct relation of
its nutrition to its own action. In inordinate action of the heart, it is ob-
served that the great force of the pulsations is commonly expended on the
first parts of the arterial tube ; so that whilst the throbbing is strong in the
aorta and immediate branches, the pulse in the radial and other distant arte-
ries is often uncommonly weak. Now the coronary arteries, which supply
the heart, are the first to profit by this partial force; and whilst they are
furnishing the tissues of the heart with the nutrient fluid, in force and abund-
ance greater than usual, distant parts may be languishing for lack of a due
supply. Thus increased action may extend from function to structure, and
continued excitement becomes perpetuated by augmented substance and
strength. But if the blood be defective in its nutrient quality, in respect to
muscular fibre, as it is in various cachectic conditions of the body, or if the
strength of the heart itself be unequal to propel the mass of blood on which
it endeavours to contract, excited action will not be backed by increased
nourishment; the contractions, although still quick and abrupt, will have
no extent of force, and the fibres, unable to expel the mass of blood to the
usual amount, will become permanently extended — spread abroad ; the walls
will be thus dilated, and the cavities enlarged. Again, these conditions
may be combined ; as when the nutrition of the heart is augmented with
the increased action, but still its force is inadequate to its task, and the walls
suffer distention at the same time that they are over-nourished." — C. J. B.
Williams's Lectures, d^-c. — P.]
Exciting causes of Hypertrophy. — According to the foregoing
opinions on the mode of ibrmation of hypertrophy, it will be appa-
rent that every circumstance capable of increasing the action of the
heart for a sufficient length of time, may be a cause of hypertro-
phy. These circumstances may be either of a nervous, or of a
mechanical nature.
1. The nervous class comprises all moral affections and all de-
rangements of the nervous function that excite long-continued pal-
pitation.
2. The mechanical class embraces all physical causes which can
either accelerate, or obstruct the circulation, and thus occasion a
preternatural pressure of the blood upon the heart.
The physical causes which accelerate the circulation, are, vio-
lent and contracted corporeal efforts of every description. In grow-
ing youths, excessive rowing is one of the most efficient. 1 have
met with numerous instances in which it has produced the effect, —
especially in Oxford and Cambridge men. forming the crews of the
racing boats. In schoolboys, I have found violent gymnastics, the
game of " hare and hounds," and actually following the hounds,
produce the same effect. These violent exercises may even occa-
sion rupture and inflammation of the valves and aorta, issuing in
incurable organic disease, — of which I have seen, several well-
marked instances. I have also repeatedly known pedestrian tours
248 HOPE ON DISEASES OF THE HEART.
amongst the Swiss and Scotch mountains, to be followed by hyper-
trophy and other diseases of the heart. It is protracted efforts that
are always the most pernicious. Feats of this kind should, there-
fore, always be discouraged.
The physical causes which obstruct the circulation are very nu-
merous. They comprise smallness of the aorta, whether congen-
ital or acquired ; dilatation of the aorta, inequalities of its internal sur-
face ; all diseases of the valves of the heart which either contract their
apertures, impede their movements, or allow of regurgitation; ad-
hesion of the pericardium; all affections of the chest that for a long
period obstruct the circulation through the lungs, as chronic catarrh,
emphysema, asthmn,1 narrowness of the chest, either congenital, or
occasioned by curvature2 of the spine, &c. ; encroachment of the
diaphragm on the cavity of the chest from the pressure of the gra-
vid uterus, of ovarian dropsy, of other abdominal tumours, but,
perhaps, above all, of long, stiff stay-bones or wooden busks, which,
by fixing the abdomen, prevent the descent of the diaphragm, and,
when the abdomen is flatulent, act with the power of a long lever
in depressing the sternum. The effect takes place even though the
stays be not very tightly laced, whereas a pretty tight band round
the waist will be borne with impunity, provided that the chest and
abdomen can expand freely above and below it.
Such are the ordinary predisposing and exciting causes of hyper-
trophy. There is strong reason to believe that inflammation is ano-
ther cause. For the last eight or ten years, I have almost invaria-
bly found, that palpitation following acute rheumatism was con-
nected, either with a persistence of the inflammation in a chronic
form, or with valvular disease or adhesion of the pericardium, re-
sulting from it. As these latter lesions are, of themselves, capable
of exciting hypertrophy, we cannot argue, from cases in which they
exist, that the hypertrophy was referable to inflammation ; we must
first select, and argue from, cases in which the inflammation was
not attended with organic lesions. Now, I believe that 1 have
seen a certain number of cases of hypertrophy, which, though un-
attended by any valvular defect or adhesion of the pericardium,
were distinctly dated from attacks of acute rheumatism, attended
with inflammation of the heart. Hence, it is to be inferred, that in
such cases, the inflammation alone was the cause of the hypertro-
phy. Assuming this as true, we may next argue back to those
cases in which the inflammation has produced valvular and other
1 1 have not found phthisis so decided a cause of disease of the heart as we
should be led to suppose from the extreme pulmonary obstruction to which
it sometimes gives rise. The reason of this appears to me to be, that, in
the early stages, when the disorganisation is not extensive, the circulation
is little embarrassed; and in the advanced stages, the mass of circulating
fluids is so much diminished, in consequence of deficient nutrition and aug-
mented cutaneous transpiration, that the heart sustains little additional
burden from the obstruction in the lungs.
2 The majority of hump-backed persons are ultimately attacked by disease
of the heart,
FORMATION AND CAUSES OF HYPERTROPHY. 249
organic lesions, and we may legitimately say that the inflamma-
tion, no less than the organic lesions, has contributed to the pro-
duction of the hypertrophy. Accordingly, it is extremely rare to
find hypertrophy absent in cases of valvular disease resulting from
rheumatic endocarditis, whereas, it is not unfrequently absent in
cases of valvular disease resulting from ordinary causes, — a result
which might be expected, since, in the inflammatory cases, there is
the co-operation of two causes, — the inflammation and the valvular
lesion.
These results of observation are countenanced by analogy ; for
there is no fact in modern pathology better established, than that
chronic inflammation, (either originally chronic or consequent on
acute,) may excite hypertrophy of various organs and tissues.
Thus, Andral, after referring one class of hypertrophies " simply to
increased exercise of the functions of the affected organ," refers
another to "an acute, but more frequently to a chronic attack of
hyperemia (inflammation). In such cases, the hypertrophy is
sometimes confined to the tissue which was originally in a state of
irritation and hypenepjia ; while, sometimes, after the tissue origi-
nally affected has returned to its natural, healthy condition, the
adjacent tissues retain a chronic form of disease, and fall into a
state of hypertrophy. Such is frequently the termination of in-
flammation of the skin and mucous membranes." (Path. Anat. i.
224). In the writer's Elements and Illustrations of Morbid Anato-
my, are coloured delineations of hypertrophy, not only of the other
tissues, but of the muscular coats of the stomach, colon, and blad-
der, connected with chronic inflammation of the mucous mem-
brane. I have seen the same in the bronchial muscles. It is very
intelligible, then, that inflammation may be similarly propagated
from the membranes to the muscular substance of the heart. The
changes of colour and consistence, which the organ undergoes un-
der these circumstances, are described in the chapter on Softening*
[M. Bouillaud is of opinion, that hypertrophy of the heart is rarely, if
ever, found as an original disease, but that it is always connected with some
other lesion, particularly with inflammation of its internal or external coat,
disease of the valves, constriction of the orifices, or obstruction in the great
1 Dr. Elliotson broached the opinion in 1820 that " hypertrophy was in
general an inflammatory disease;" and his "reason for supposing so, was,
that it was a very common effect of pericarditis." (Lum. Lectures, p. 25.)
I think that others in this country had previously entertained a similar opi-
nion. I presume that it was not entertained in France, because M. Bouil-
laud, so late as 1835, introduces it as a novelty, (apercus nouveaux,) of his
own discovery. (Traite, ii. p. 457.) Dr. Elliotson has greatly overstated the
case in saying that hypertrophy is in general an inflammatory disease: nor
can I at all subscribe to his opinion that the inflammatory is the only curable
variety of this disease. (Med. Gaz., June 22, 1833, p. 377.) On the contrary,
I have found it the least curable, on account of the frequency and severity
of valvular and other complications; whereas, uncomplicated hypertrophy,
from ordinary causes, is, in a large proportion of cases, very curable by the
treatment presently to be described.
250 HOPE ON DISEASES OF THE HEART.
vessels. The obstacle to the circulation from these different pathological
conditions being, according to him, the source of all the symptoms usually
ascribed to hypertrophy.
But, Laennec, who had observed that hypertrophy frequently existed
without valvular or other obstruction, and that it was not accompanied by
any evidence of inflammation, did not consider these pathological states as
essential to the development of hypertrophy.
Pathologists, generally, have entertained similar opinions to those of
Bouillaud, which in fact are like those of Corvisart: but the recent re-
searches of Doctor Clend'inmng, go far to show that hypertrophy of the
heart may exist, free from any of the morbid states alluded to. Of upwards
of five hundred autopsies made by him of patients dying of various diseases
in the hospital to which he is attached, (Mary-le-bone Infirmary,) where
every variety of disease is admitted, — above one hundred and seventy, that
is, above one third of the whole, proved to have had heart disease in some
form : five sixths of these were cases of hypertrophy, uncomplicated, he as-
serts, with other diseases of the heart, such as pericarditis, endocarditis, or
valvular disease. In about thirty cases only, or in about one sixth of the
whole, well marked valvular disease was detected ; in all these last cases,
with but one exception, hypertrophy existed. Hence it would appear to be
a pathological law, that, wherever valvular disease exists for some time,
causing an obstacle, hypertrophy of the heart will result as a consequence;
but, that the hypertrophic state is not necessarily dependent upon the lesions
mentioned, inasmuch as, in a large majority of the cases, none of these patho-
logical conditions existed. From these facts it may be assumed, that any
cause which may affect, either, the motory functions of the heart, or its
nutrition, or both together, may cause its hypertrophy. — P.]
SECTION III. — Order of succession in which the several compartments of the
Heart are rendered hypertrophous by an obstacle before them in the course of the
circulation.
As an obstacle to the circulation operates on the heart in a retro-
grade direction, the cavity situated immediately behind it is the
first to suffer from its influence. Accordingly, all the impediments
seated in the aorta, its mouth, or the arterial system, act primarily
on the left ventricle, which being likewise exposed to the heaviest
burden when the circulation is accelerated, has to conflict against a
greater variety of exciting causes of hypertrophy, than any other
cavity of the heart. On this account, therefore, as well as from
the thickness of its parietes, it is subject to hypertrophy in a greater
degree than any other.
So long as the left ventricle is capable of propelling its contents,
the corresponding auricle, being protected by its valve, remains
secure. Hence, in a large proportion of cases, the auricle is per-
fectly exempt from disease, while the ventricle is even enormously
thickened and dilated. But when the distending pressure of the
blood preponderates over the power of the ventricle, its contents,
from not being duly expelled, constitute an obsfacleto the transmis-
sion of the auricular blood. Hence the auricle becomes over-dis-
tended, and the obstruction may be propagated backwards through
the lungs to the right side of the heart, and there occasion the same
series of phenomena. When the obstruction thus becomes univer-
FORMATION AND CAUSES OF HYPERTROPHY. 251
sal, as is frequently the case, it may either happen that all the cavi-
ties are thickened, or those only which, from their conformation,
have the greatest predisposition to it.
When the mitral orifice is contracted, especially if the aperture
be very small, the left ventricle, being insufficiently supplied with
blood, is not stimulated to its ordinary contractile action, and
consequently becomes emaciated and occasionally flaccid or
softened. Meanwhile, the left auricle, having to struggle against
the contracted valve in front, and also to sustain the distending
pressure of the blood flowing in from the lungs, invariably be-
comes thickened and dilated. The engorgement, extending back-
wards through the lungs to the right ventricle, often occasions its
hypertrophy and dilatation ; under which circumstances, namely,
hypertrophy of the right ventricle and contraction of the mitral
valve, the lungs suffer in a pre-eminent degree : for, being exposed
to the augmented impulsive power of the right ventricle behind,
and incapable of unloading themselves on account of the straitened
orifice in front, their delicate and ill-supported vessels are strained
beyond the power of resistance. If, therefore, they cannot disgorge
themselves sufficiently by a copious secretion of watery mucus,
they effuse blood by transudation into the air-vesicles and tubes,
and form the disease denominated pulmonary apoplexy. I have
found this affection to occur more frequently under the circum-
stances described, namely, great contraction of the mitral valve,
with, or even without, hypertrophy and dilatation of the right ven-
tricle, than under any other.1
When the mitral orifice is permanently patescent, so that, at each
ventricular contraction, blood regurgitates into the auricle, this
cavity suffers in a remarkable degree: for it is not only gorged with
the blood which it cannot transmit, but, in addition, sustains the
pressure of the ventricular contraction. Permanent patescence of
the mitral orifice, therefore, constitutes an obstruction on the left
side of the heart ; and the effect of this, as of contraction of the ori-
fice, may be propagated backwards to the right side. The regurgi-
tation is always considerable when it renders the pulse small and
weak.
When the impediment to the circulation is primitively seated in
the lungs, the right ventricle, situated immediately behind them, is
the first to experience its influence ; and when the cavity is so far
overpowered by the distending pressure of the blood as to be inca-
pable of adequately expelling its contents, the obstruction extends
to the auricle, — the process being exactly the same as that which I
have already described above, in reference to the left ventricle
and auricle.
Obstruction in the right auricle, whether from this or any other
1 This fact has subsequently been corroborated by Dr. Wilson, in a paper,
with cases, read to the College of Physicians. I have more recently found
that softening of the heart is also a frequent cause of pulmonary apoplexy.
(See Softening.)
252 HOPE ON DISEASES OF THE HEART.
cause, presents an obstacle to the return of the venous blood, and
therefore causes retardation throughout the whole venous system.
Nor is this all ; for the retardation is propagated through the capil-
laries to the arterial system, and thus at length returns in a circle
to the heart. In this way is explained what at first sight appears
an anomaly ; namely, that the left cavities are sometimes rendered
hypsrtrophous by an obstruction in the heart situated behind them
in the course of the circulation, as, for instance, when the left ven-
tricle is rendered hypertrophous by a contraction of the mitral
orifice.
["When the auriculo-ventricular orifice is contracted, we occasionally
find dilated hypertrophy of the right ventricle combined with contracted
hypertrophy of the left. It has puzzled pathologists to account for this hy-
pertrophy of the left ventricle when its task must be diminished by its
receiving less blood to propel, from the left auricle. It has been attempted
to explain it by the left ventricle, feeling the obstacle at its own auricular
orifice through the whole course of the arteries, capillaries, veins, the right
side of the heart, and the pulmonary vessels; a round about explanation
truly, and one that supposes a degree of distention of all these parts that
is very rarely seen. Then Dr. Copeland urges this case as an argument for
his favourite notion of an active expansion of the ventricles, which I cannot
admit to be warranted by any physiological analogies. But how very sim-
ple is the true cause of this hypertrophy, if I understand it aright! Why
should not the excitement of the whole heart dependent on the distention
of all its other cavities produce increased action, and eventually increased
growth of the left ventricle also? Is it possible that the same fibres which
encircle both ventricles can be excited in one and not in the oiher? No,
surely ; the left ventricle, naturally the strongest and most active, is thus
excited by sympathy or continuity of irritation ; and when its walls become
increased under this influence, the cavity must be contracted from the small-
ness of its contents." — C. J. B. JVilliams''s Lectures. — P.]
The reader must here be again reminded that the exciting causes
of hypertrophy are equally those of dilatation ; and that, supposing
no unknown agencies to interfere, as may sometimes possibly hap-
pen, it depends on the proportion which the cause bears to the re-
acting energy of the cavity exposed to its influence, whether that
cavity become affected with hypertrophy, with dilatation, or with a
combination of the two.
It may be said, generally, that when congestion is constant in a
cavity, dilatation is more commonly the result ; and that when
there is only resistance to the expulsion of the blood, without con-
stant engorgement of the cavity, it is more common for hypertro-
phy to be produced. Contraction, for instance, of the aortic orifice,
causes hypertrophy of the left ventricle in a greater degree than
dilatation ; whereas, patescence of that orifice, attended with re-
gurgitation and constant engorgement of the cavity, causes dila-
tation in a greater degree than hypertrophy. *
Hypertrophy with contraction most commonly proceeds from
straitening of an orifice. Thus the greatest hypertrophy with con-
traction of the right ventricle upon record, was accompanied with
straitening of the pulmonary orifice to two lines and a half in
FORMATION AND CAUSES OF HYPERTROPHY. 253
diameter (Case 87 by M. Bertin). I have met with a very similar
case, and several, connected with malformation of the heart, are on
record.
It may be useful to subjoin a list of the various forms and com-
binations of hypertrophy and dilatation, and to show the compara-
tive frequency of their occurrence. On the latter point I shall
offer the results of my own observation, and I believe that they
correspond very closely with those of others.
The diseases are of more frequent occurrence in proportion as
they are higher in the following scale.
1. Hypertrophy with dilatation of the left ventricle, and a less
degree of the same in the right.
2. Hypertrophy with dilatation of the left ventricle, with simple
dilatation of the right.
3. Simple dilatation of both ventricles.
4. Simple hypertrophy of the left.1
5. Dilatation with attenuation of the left.
6. Hypertrophy with contraction of the left.
7. Hypertrophy with contraction of the right.2
Of the Auricles.
1. Distention, particularly of the right, from congestion during
the period of dissolution.
2. Dilatation with hypertrophy.
3. Simple hypertrophy.
4. Hypertrophy with contraction, which is almost unknown.
SECTION IV. — Pathological effects of Hypertrophy, and mode of their production.
M. Laennec supposes the general symptoms of all organic dis-
eases of the heart to be nearly the same (De l'Auscult. torn. ii. p.
487). It may be said, without prejudice to one who has done so
much, that, on this subject, both he and all the authors who
preceded him, have entertained inaccurate ideas. They had
studied these diseases in the aspect under which they most
commonly present themselves ; namely, complicated one with
another : and it is unquestionable that, when so viewed, they
display a general similarity in their symptoms. But it had never
occurred to those authors to analyse each disease in an isolated
form. When so examined, although certain symptoms are common
to all, they severally manifest differences of a striking kind, ob-
viously dependent on their respective organic peculiarities, and
which may, therefore, be fairly regarded as the essential and
diagnostic characters of each.
1 M. Bouillaud thinks that there is scarcely one case of simple hypertro-
phy of the heart in general, for twenty of hypertrophy with dilatation.
2 M. Bouillaud gives eight cases of this for five of the same in the left
ventricle, but he is not sure that further observation would establish the
majority in favour of the right.
254 HOPE ON DTSEASES OF THE HEART.
M. Bertin has the merit of having been the first to display-
in a clear light the essential pathology of hypertrophy. His dis-
tinguished talent for generalisation, however, has, I believe it
will be allowed, carried him a degree too far. He contends
that authors are wrong in having assigned to hypertrophy or
active aneurism, as its symptoms, dyspnoea, suffocation, violet in-
jection of the face, engorgement of the lips and of the venous
capillaries in general, passive hemorrhages, and serous infiltration.
He contends that these are the signs, not of hypertrophy, but of a
coexistent lesion : viz. a contracted orifice, or any other affection
capable of obstructing the circulation; and that pure, uncompli-
cated hypertrophy is characterised by signs of increased activity
and energy of the circulation; instead of by dropsy and the other
signs of its retardation. x
That this is true in reference to the 'pure, uncomplicated form
of the disease, before embarrassment of the capillary circulation
has taken place, will not be denied by any one who has had op-
portunities of verifying the symptoms by dissection. But M. Ber-
tin is not, in my opinion, supported either by sound observation or
by analogy when he says that serous infiltration and the whole
class of symptoms bespeaking an obstructed circulation, are totally
foreign and repugnant to hypertrophy. The truth I believe to be,
that the very same energy of the circulation which gives rise, as
he admits, to active hemorrhages, apoplexy, (fee, causes, as its
next effect, and in the more advanced stages of the disease, en-
gorgement of the arterial capillary system; the necessary conse-
quence of which is, serous infiltration and more or less of all the
other symptoms indicative of retardation of the blood. The pro-
cess appears, in fact, to be strictly analogous to that by which
serous infiltration is produced in cases of erysipelas, inflammatory
anasarca, acute rheumatism, &c. I would not be understood by
this to mean that active capillary congestion is identical with
inflammation, but that, as the effects of the two are sometimes
the same, we are compelled to admit a close analogy in the mode
of their production. It is now, indeed, very generally allowed
that active congestion only differs from inflammation in being a
degree less.
M. Bertin himself unconsciously shows that hypertrophy may
produce an obstacle to the circulation, for he says that, when the
heart is enormously enlarged, the respiration is impeded in a very
eminent degree (d'une maniere tres notable. Bertin, p. 359).
Now, what is the real cause of this impeded state of the respira-
tion ? He ascribes it to the encroachment of the heart upon the
lungs ; but this cause is inadequate : for tumours of a much larger
size, as, for instance, aneurisms of the aorta," malignant tumours,
1 I now find that M. Bouillaud is the author of these opinions, as they are
transplanted into his own more recent work, vol. ii. p. 445. Seven years
of additional observation have only the more convinced me that they are
erroneous.
&c. have existed in the chest, even for years, without producing
similar inconvenience. It is not, therefore, to compression of the
lungs that we are to look, as the cause of the dyspnoea and dropsy ;
but, clearly, to the heart itself;1 and on reflection it is very con-
ceivable that, when the blood is poured in increased quantity &nd
with unwonted impetuosity into the capillary vessels of the lungs,
so as to gorge and obstruct them, the obstruction being universal,
must be greater than when a free channel is left open through a
portion of the organ, even though limited, as one half or a third;
for we constantly see, in cases of phthisis, and of chronic pleuri-
tic effusion, that such a portion is sufficient for maintaining the
circulation.
The primary effect of universal obstruction of the lungs by
engorgement, is, to produce oedema of their cellular tissue, and
dyspnoea. The secondary effect is, to gorge the right side of the
heart, and thus impede the return of the venous blood from the
system at large ; which co-operates with the increased energy of
the arterial circulation in producing capillary congestion and its
consequence, anasarca.
It must be admitted, however, that hypertrophy does not produce
serous infiltration so readily and promptly as a direct, primary
obstacle to the return of the venous blood ; a fact which admits of
a rational and obvious explanation. When there is an obstacle to
the return of the venous blood, suppose, for instance, contraction
of the tricuspid, pulmonic, or mitral orifice, two causes conspire to
produce the capillary congestion ; namely, the direct pressure of
the arterial vis-a-tergo, and the retrograde pressure of the retarded
venous blood. But when the latter pressure does not exist, when
the veins freely receive and transmit their natural proportion of
blood, the force of the arterial circulation must be very greatly
increased, before it can so far overcome the elasticity of the capil-
laries as to give rise to engorgement and infiltration.
This satisfactorily accounts for the difference in the history and
character of infiltration as resulting, on the one hand, from pure
hypertrophy, and, on the other, from contraction of a valve or
other primary obstacles to the circulation, amongst which (for
reasons to be explained in the chapter on Dilatation) I include
dilatation with attenuation, and softening. In the former case, it
appears late, is generally moderate in extent, and requires for its
production an aggravated form of hypertrophy ; in the latter cases,
it appears comparatively early, is more copious, and yields with
less facility to remedies. It will, however, be shown in the chap-
ter on Valvular Disease, that the dropsy seldom comes on in any
considerable degree till hypertrophy, dilatation, or softening has
been superadded to the valvular lesion.
The same reasons that account for the tardy occurrence of
dropsy in pure hypertrophy, account, likewise, for another charae-
1 M. Bouillaud now admit-, the co-operation of this (Traite, ii. p. 445).
256 HOPE ON DISEASES OF THE HEART.
teristic of this malady, when moderate in degree ; namely, the
slight and transitory nature of the attacks of dyspncea. For, if
the quantity of blood impelled into the lungs by the right ventri-
cle, and the force with which it is impelled, are not very exces-
sive, the pulmonary veins are capable of relieving the engorgement
almost as quickly as it takes place, and, consequently, the hurry
of the respiration subsides promptly after the removal of its
exciting cause.
The sum, then, of all that has been said, is, that pure hyper-
trophy at first gives rise to increased force and activity of the
circulation ; and that, when this force surmounts the natural tonic
power of capillaries, (which is apt to be the case in the late
stages of the disease,) congestion, infiltration, and the other phe-
nomenona of an obstructed circulation, ensue.
To these principles an exception presents itself in hypertrophy
with contraction, when the cavity of the ventricle is so small as
to be incapable of transmitting the natural quantity of blood. In
this case, supposing the left ventricle to be the one affected, the
arterial circulation sustains a diminution of force and activity;
and, whether the one ventricle or the other be affected, it creates
an obstruction tantamount to that produced by valvular contrac-
tion, and, on the same principles, generates dropsy and the other
phenomena of a retarded circulation. I have met with three or
four cases in which the ventricle was reduced to the size of a
small walnut.1 Such cases, however, are very rare.
The effects of simple hypertrophy and hypertrophy with dila-
tation of the left ventricle, on the brain, are so pre-eminently
important, that it is necessary to advert particularly to this sub-
ject, for the purpose of bringing it prominently into view.2
Since the researches of the present day have demonstrated that
even a slight thickening of the walls of the heart constitutes a
morbid state ; and have unfolded to view the connection subsisting
between that state and a train of symptoms formerly either wholly
overlooked or attributed to other causes ; instances of apoplexy
supervening upon hypertrophy have been so frequently noticed,
that the relation of the two as cause and effect, is, in my opinion,
one of the best established doctrines of modern pathology. Eight
or nine cases of suddenly fatal apoplexy, and numerous cases of
palsy, from hypertrophy, have, within a few years, fallen under
my own observation. In the majority of them the patient exhi-
bited what is commonly called the " apoplectic constitution;"
that is, a robust conformation, a plethoric habit, and a florid com-
plexion : in others, these characters were absent; but the total num-
ber of the cases of apoplexy from hypertrophy, is much greater
than I have witnessed, during the same period, of apoplexy from
causes independent of hypertrophy. Whence I am led to believe,
' See one by the writer; Lond. Med. Gaz. Sept. 5, 1839, p. 422.
2 I exclude hypertrophy with contraction, foi the reasons mentioned in
the preceding paragraph.
CAUSES AND EFFECTS OF HYPERTROPHY. 257
with M. Richerand and MM. Bertin and Bouillaud, that hypertrophy-
forms a stronger predisposition to apoplexy than the apopletic con-
stitution itself; and that, in most instances, those persons who pre-
sent the apoplectic constitution in conjunction with symptoms of
increased determination to the head, are, at the same time, affected
with hypertrophy.
During the last eight years, I have had much additional reason
for adhering to the same opinion. It has also been advocated by
M. Brichteau, in the Clinique de l'Hopital Necker, M. Bouillaud,
and numerous other writers. It appears to me, indeed, that the
full extent of the connection between the diseases of the head and
those of the heartj — in reference, not only to hypertrophy, but also
to dilatation, softening-, and diseases of the valves, — has not yet
been duly estimated, either by the writers referred to, or by the
general body of the profession.
From the 12th December, 1832, to the same date in 1834, thirty-
nine patients who had died of apoplexy, were examined post ?nor-
tem in the St. Mary-le-bone Infirmary, to which I was then physician.
The following are the results, according to the journals of Mr.
Hutchinson, the able resident surgeon of the institution: —
Of the thirty-nine cases, four died of apoplexy between birth and
forty; nine, between forty and fifty; six, between fifty and sixty;
seven, between sixty and seventy; eleven, between seventy and
eighty; one, between eighty and ninety; and one, between ninety
and a hundred.
Hence it would appear, that the periods of life during which
fatal apoplexy is most prevalent, are between forty and fifty, and
between seventy and eighty.
We have now to examine in what proportion of these cases dis-
ease of the heart existed.
In four out of the thirty-nine, the heart was found "quite
healthy." In eight cases more, no remark is made in the journals
as to its condition ; it may therefore be presumed to have been
healthy. This affords a total of twelve cases out of thirty-nine, in
which the heart was sound : in the remaining twenty-seven, it was
diseased.
Thus, taking all the ages collectively, disease of the heart ac-
companied fatal apoplexy in no less than twenty-seven out. of thirty-
nine — i. e. 9-13 or nearly 3-4.
We will now examine at which of the above periods of life dis-
ease of the heart, in connection with fatal apoplexy, was most
prevalent.
Between birth and forty, disease of the heart was not found in
any of the four fatal cases that occurred within those dates.
Between forty and fifty, it occurred in eight out of nine ! — a remark-
able increase. Between fifty and sixty, it occurred in four out of
six, — a decrease. Between sixty and seventy, it occurred in three
out of seven — a further decrease ; and between seventy and eighty,
it occurred in ten out of eleven ! — another remarkable increase.
10— e 17 hope
258 uov:: on diseases of the heart.
It would thus appear that the periods of life during which fatal
apoplexy is most prevalent, are precisely those in which concomi-
tant disease of the heart is of most frequent occurrence ; namely,
between forty and fifty, and between seventy and eighty.
It was stated above, that, taking all ages together, disease of the
heart occurred in nine cases out of thirteen, or nearly three fourths,
of fatal apoplexy. Now this proportion is, I apprehend, much
greater than is generally imagined or believed ; and it sufficiently
evinces the importance, in medical practice, of carefully studying
how far the state of the heart and that of the brain, may be allied
as cause and effect.
But, in the two apoplectic periods of life, if I may be allowed the
expression, viz. between forty and fifty, and between seventy and
eighty, the proportion is much greater ; for, instead of being nine
out of thirteen, it is in the proportion of nine out of ten, and ten
out of eleven. Hence, it is desirable to direct our attention, in the
treatment of apoplexy, to these two periods more especially ; and,
in order to do it with effect, it is necessary to investigate the rea-
sons why fatal apoplexy occurs in connection with disease of the
heart, during these periods in particular.
Now, on examining the cases occurring between the ages of
seventy and eighty, seven out of ten present ossification of the
heart. On the other hand, between forty and fifty, disease of the
muscular structure of various kinds, prevailed, while ossification
was comparatively rare.
Hence it appears deducible, as a generalisation, that it is disease
of the muscular structure more especially, which causes apoplexy
in the earlier period of its prevalence ; and that it is mainly ossifi-
cation which occasions it in the more advanced period.
It will now be asked, why disease of the muscular structure
occasions fatal apoplexy between the ages of forty and fifty in par-
ticular. To this question, the history of disease of the muscular
structure affords a reply. Such disease is not, in general, expe-
ditiously fatal. It usually commences insidiously, and steals on
gradually — often subsisting from ten to twenty years, or more,
before it produces its fatal effects. If, then, we consider that it is
principally between the ages of twenty-five and forty that the
causes of disease of the muscular structure are brought into opera-
tion ; if we reflect that this is the period when intellectual exertions
are the most intense and sustained, — when the exciting and de-
pressing passions have the strongest and most permanent hold, —
when the physical system is subject to the greatest variety, and
severity, and continuity of efforts ; all of which causes, by preter-
naturaily stimulating the heart, predispose it to muscular disease;
if we finally reflect that it is before forty that rheumatic inflamma-
tion of the heart — that fertile source of hypertrophy, (fee. is most
prevalent, we shall not be surprised that the seeds of destruction,
sown during this period, should yield their fruits during the subse-
quent period ; namely, between forty and fifty.
CAUSES AND EFFECTS OF HYPERTROPHY. 259
It will next be asked, why ossification causes fatal apoplexy
between the ages of seventy and eighty in particular.
It is not until towards the age of sixty that the ossific tendency
which characterises old age, comes very decidedly into operation.
Between the ages of sixty and seventy, it makes silent progress in
the heart, and between seventy and eighty, it produces its fatal
effects ; these effects being, no doubt, assisted by disease of the cere-
bral arteries, which also accompanies the progress of decay.
An able writer, (in the Med. Gaz. December 12, 1835, p. 412 :
also, in a paper read to the College of Physicians.) who thinks that
hypertrophy and apoplexy are connected by nothing more than
mere coincidence, and that i: the true explanation of the hemor-
rhage in the brain, is to be found in the diseased state of the cerebral
arteries," has applied this explanation to the above thirty-nine cases.
Too much importance certainly cannot be attached to the effect of
diseased cerebral arteries in producing apoplexy ; and, in order to
show that I had not overlooked it, as the above writer states, I may
here be permitted to reproduce a passage written five years previous
to his strictures, in the first edition of this work. (p. 160.) " In the
arteries at the base of the brain, calcareous and other degenerations
are remarkably frequent, and are a principal cause of rupture of the
vessels and apoplectic effusion. It is rare, indeed, to meet with
instances of such effusion, exclusive of those from external violence,
in which some disease of these arteries may not Le detected ; and
it is remarkable that the disease of the artery is in general con-
nected with hypertrophy of the left ventricle: whence it appears
to be a result of over-distention, to which the cerebral arteries are
more obnoxious than any others, in consequence of their being
destitute of a cellular coat, and also of being ill supported by the
pulpy yielding substance of the brain."1
But the argument of the writer in question is illogical: for, if
diseased cerebral arteries can produce apoplexy while there is a
natural stnte of the circulation through the heart, they will, a for-
tiori^ produce it when there is either a preternaturally strong, or
an obstructed, circulation through the organ, since both the one
and the other tend to congest and strain the cerebral vessels. The
truth manifestly is, that the cardiac and the cerebral diseases are
each separately capable of giving rise to apoplexy; and that, when
they co-exist, the effect is produced in a higher degree.
The same writer has adduced a case of hypertrophy of the left
1 It is satisfactory to see different observers come to the same conclusions.
Thus, M. Bouillaud, not aware of the above passage, says, in 1835, "I shall
notice a circumstance hitherto neglected by observers, namely, the frequency
of cretaceous degeneration, and therefore fragility, of the cerebral arteries,
in subjects who die of cerebral hemorrhage and who are affected with hyper-
trophy of the left ventricle of the heart." (Traite, ii. p. 451.) The notice of
hypertrophy is the more remarkable, as this writer almost invariably ascribes
arterial diseases to inflammation, and not to over-distention, an idea which
originated, I believe, with myself.
17*
260 HOPE ON DISEASES OF THE HEART.
ventricle with " an unusually small cavity, and with a contraction
of the mitral valve, through which nothing larger than one's thumb
could easily pass," as "directly opposed to the opinion generally
prevalent that hypertrophy is a physical cause of apoplexy." For
he contends that so small a ventricle would propel a diminished,
instead of an increased quantity of blood into the brain : conse-
quently, that the apoplexy was occasioned, not by the hypertrophy,
but by disease of the cerebral arteries. This case, however, proves
nothing against the doctrine, that hypertrophy is a cause of apo-
plexy; for it is, unluckily, a case of exception, as above described at
p. 256, and which, as being an exception, I have excluded from the
heading of the present subdivision. Hypertrophy with contraction
does not produce the effects of hypertrophy, but of a valvular or
other obstruction. Besides, there was, in this case, extreme con-
traction of the mitral valve, which would neutralise the special
effects of any form of hypertrophy ! The case is no less unsuitable
for establishing the writer's own doctrine, viz. that disease of the
cerebral arteries is the true cause of hemorrhage in the brain, than
it is for subverting that of his opponents ; for it will not be denied
that a mitral valve contracted to the size of a thumb, constitutes
one of the most serious obstacles to the return of the venous blood
from the whole system : consequently, the brain must have been
congested, and such congestion would powerfully co-operate with
disease of the cerebral arteries in producing the rupture of those
vessels.
As the opinions of the writer in question justly carry much
weight, it has been the more necessary to point out the unsound-
ness of his reasonings in the present instance, in order to prevent
the dissemination of a pernicious error.
Such are the grounds on which I believe that not only hyper-
trophy, but all kinds of obstructions to the circulation through the
heart, contribute to the production of congestion, either active or
passive, and of apoplexy.
Nor is it to apoplexy alone, but, on the same principle, to cere-
bral inflammations and irritations of every description, and even
to inflammatory action in general, that hypertrophy of the left
ventricle gives a tendency. The history of individuals affected
with it, not unfrequently presents a striking narrative of violent
headaches, brain fevers, various inflammatory complaints, and
states of great nervous irritability and excitation. This remark
has, I understand, been corroborated by the recent researches of
Dr. Clendinning in the St. Mary-le-bone Infirmary. As the ophthal-
mic artery is derived from the carotid within the cranium, the eye
participates with the brain in the effects of hypertrophy, and is
vascular, brilliant, and prone to ophthalmia. The wasting away of
the eye which Professor Testa has remarked as one of the effects
of disease of the heart, is, with good reason, supposed by MM.
Bertin and Bouillaud to be connected with ossification of the oph-
thalmic arteries.
CAUSES AND EFFECTS OF HYPERTROPHY. 26 I
The shock of an hypertrophous left ventricle may, to a certain
extent, be intercepted, and its effects on the brain counteracted, by
contraction of the aortic orifice. A patient was under the care of
Mr. Babington, at St. George's Hospital, September 16, 1829, for a
surgical complaint, in whom the walls of the left ventricle were an
inch thick, without any change of the cavity ; and the aortic and
mitral orifices were respectively encircled by a ring of bone as
thick as a writing quill. The two valves, though overspread with
calcareous scales, were capable of discharging their functions.
(See Fig. 15). Notwithstanding this extraordinary state of dis-
ease, the patient had attained the age of eighty without manifesting
symptoms of diseased heart sufficient to arrest his own attention,
or that of his medical attendants. His advanced age, indeed,
proves that they could not have existed in any considerable degree.
In this case, therefore, the valvular contraction appears to have
been exactly sufficient to countervail the hypertrophy, and main-
tain the circulation in a state of equilibrium. The generality of
authors, however, have greatly over-rated the power of contraction
of the aortic orifice to counteract the effects of hypertrophy on the
brain. They have supposed that a moderate, and even a slight
degree of contraction, is sufficient for the purpose. There can be
no greater error ; and it is one into which they could not have
fallen, had they been aware that such a degree of contraction has
very little effect in diminishing the strength, tension, and regularity
of the pulse. To this subject I shall revert in the chapter on Val-
vular Disease.
In the first edition, I quoted a passage from Bertin and Bouil-
laud, stating, that, as hypertrophy of the left ventricle caused
cerebral hemorrhage, so hypertrophy of the right caused active
pulmonary hemorrhage. I have not, however, subsequently found
this coincidence to be sufficiently frequent to authorise its adoption
as a general rule. I have not, in fact, been able to meet with a
single case in which I could refer the haemoptysis to hypertrophy
of the right ventricle exclusively, though I have seen several in
which it was connected with hypertrophy of both. Dr. Watson
and M. Bouillaud have made similar observations, and the latter
gentleman, in his more recent Treatise, has withdrawn the passage
from his text, and placed it, as questionable, in a note. He asks
whether the rarity of pulmonary hemorrhage is not partly attri-
butable to the absence of disease of the pulmonary artery. I
should think that this question may safely be answered in the
affirmative. Further causes may be, that the right ventricle is
seldom hypertrophous to a considerable amount without contrac-
tion of its cavity, by which the quantity of blood expelled into the
lungs is diminished ; also, that when the pulmonary vessels are
gorged, an effort is immediately made by increased respiration to
relieve them, — a relief which is not enjoyed by the cerebral vessels.
[" The pathological effects of hypertrophy will necessarily vary according
262 HOPE ON DISEASES OP THE HEART.
to its degree, the part which it affects, and the other lesions with which it
may be complicated.
The' commonest and most important form is that affecting the left ventri-
cle, and manifesting its effects on the general circulation and its functions.
If the hypertrophy predominate, and be not counteracted by any valvular
defect, there will be an increased strength of the arterial pulse, which will
commonly be felt most in the arteries nearest to the heart, but it may extend
to the whole arterial system. You can readily understand that the increased
force of the arterial current may occasion various disorders of function
and structure in the several viscera and tissues of the body. In the first
place, it may cause dilatation and other changes in the coats of the arteries,
especially those that more immediately feel its force, the ascending portion
and arch of the aorta. Then as conducted into various tissues and organs,
it may excite and disturb their functions, exalt their sensibility, and espe-
cially dispose them to inflammation, serous effusion, and hemorrhage, or
aggravate any inflammations, irritations, or hemorrhages, when they occur.
Hence apoplexy and phrenitis, epistaxis, ophthalmia, and various inflam-
matory affections of different parts of the body, have been traced to this form
of disease of the heart. In time, the strong pulse accompanying hypertro-
phy of the left ventricle may cause an increased or modified deposition of
nutriment in the different tissues which it reaches, particularly the paren-
chyma of viscera. The kidneys afford the best illustration of this, because
they receive their blood only from the arterial system. In hypertrophy of
any standing, they are generally found enlarged, and otherwise diseased,
and often presenting the granular albuminous deposit which has been de-
scribed by Dr. Bright. The lungs and the liver are also very commonly
increased in substance, but this must be in many instances partly referred
to the obstructed venous circulation which so frequently accompanies hyper-
trophy of the left ventricle; being another consequence of its cause. The
modification of nutrition especially affects the vascular system, whence arises
thickening or ossification of the coats of the small arteries of the brain; and
in the rupture of these, there appears another mode in which hypertrophy
may lead to apoplexy.
Hypertrophy of the right ventricle is commonly supposed to be a cause of
congestions, inflammations, and hemorrhage, in the pulmonary tissues ; but
as these effects are seldom observed where there is not also some cause of
obstruction to the onward flow of blood through the left side of the heart, it
is uncertain what share the hypertrophied right ventricle may have in pro-
ducing them. In fact, if you remember that its auricular valve is not formed
to close completely on an accumulating mass of blood, but permits regurgi-
tation when the ventricle is distended, you can conceive that the pulmonary
textures are not likely to suffer from its pulsations, unless their vessels are
first distended by some other obstructing cause, in, or beyond them. In that
case, the force of the right ventricle must be felt; and when it becomes so
much distended as to open its auricular valves, this force is then in part
expended backwards into the auricles and veins, causing the venous swell-
ing and pulsation often conspicuous in the jugulars. This venous obstruc-
tion, when considerable or permanent, leads to other effects, such as
congestions in the portal system and in the sinuses of the brain; whence
arise hepatic and gastric disorders, headaches, cerebral oppression, and apo-
plexy, and especially dropsical effusions of various kinds. These backward
effects are the more likely to ensue when the right ventricle is much dilated
as well as hypertrophied; whereas the effects on the pulmonary textures,
congestion, hemorrhage, hypertrophy, and excessive bronchial secretion,
depend rather on the increased strength, without much enlargement of the
ventricle." — C. J. B. Williams' ]s Lectures, <^c] — P.
SIGNS AND DIAGNOSIS OF HYPERTROPHY. 263
SECTION V.— Signs and Diagnosis of Hypertrophy.
The signs of hypertrophy are of two classes : the first, called
general, consists of its effects on the functions of the economy at
large; and the rationale of these signs is fully explained in the
preceding section : the second, for which physical is the most
appropriate designation, comprises the impulse and sounds of the
heart and the resonance of the praecordial region on percussion.
According to my experience, neither of these classes of signs,
taken separately, is sufficient to indicate disease of the heart, in
all cases, with complete certainty : taken conjointly, they render
the diagnosis so easy, that a material error can scarcely be com-
mitted. They should never, therefore, be dissociated. At the
same time, truth requires the admission that a rude, general
diagnosis of marked cases in the advanced stage, [but of no others,)
can be made by general signs alone, as was done before the dis-
covery of auscultation : also, that many cases of hypertrophy, and
nearly all of valvular diseases when yielding distinct murmurs,
admit of a positive and precise diagnosis, even in the earliest
stages, by physical signs alone.
General Signs. — As a systematic arrangement of signs facili-
tates their registration in the memory and their employment in
the process of catechising a patient, it may not be irrelevant to
state that, in describing those of hypertrophy, I shall follow the
course of the circulation ; commencing, after having noticed the
action of the heart, with the circulation through the lungs, pro-
ceeding to that through the aortic system, and concluding with
that through the veins.
The description of symptoms which I am about to offer, refers,
it must be distinctly understood, to simple hypertrophy, (without
valvular or vascular disease,) when it is not otherwise stated : the
symptoms of hypertrophy with dilatation, which will be glanced
at incidentally, are only an aggravated degree of the same, — as the
reader will sufficiently understand, if duly acquainted with the
foregoing principles relative to the formation and effects of these
diseases. When the dilatation predominates over the hypertrophy,
the symptoms, of course, approximate more nearly to those of
dilatation (vid. Dilatation). The symptoms of hypertrophy with
contraction will also be noticed incidentally with those of simple
hypertrophy; but it may here be repeated, in general terms, that,
when the contraction is considerable, it constitutes an obstruction
to the circulation tantamount to a valvular disease, as explained
at p. 256.
1. Palpitation. — By this is to be understood, a morbidly in-
creased action of the heart both as to strength and frequency.
As the hypertrophous heart acts with an energy which, even in
its tranquil state, verges on palpitation, and which, under the
slightest excitement, actually amounts to it, the patient experi-
264 HOPE ON DISEASES OF THE HEART.
ences the consciousness of his " heart beating," more uninter-
mittingly than in any other disease of the organ. It is aggravated
by stimulants of any description : as efforts, particularly that of
ascending; mental emotion; flatulence; acidity or bile; spiritu-
ous or highly seasoned ingesta, and sometimes by a full meal of
any kind. The violence of the attack, in the early stages, generally
subsides promptly after the operation of the exciting cause has
been suspended, and little remains but a slight sense of pulsation in
the precordial region. Many, especially of the working classes,
become so accustomed to this, that, from unconsciousness, they
deny its existence. The practitioner, therefore, should never trust
to their report, but explore for himself with the hand and stetho-
scope. In the advanced stage, however, of hypertrophy, and still
more of this conjoined with dilatation, when the capillary circula-
tion has become embarrassed, the paroxysms of palpitation are
very severe and prolonged, though they never attain that fearful
extreme of violence and obstinacy which is witnessed in cases
complicated with valvular, or aortic disease, or adhesion of the
pericardium.
2. Dyspnoea. — While the enlargement of the heart is moderate,
and before dropsy has supervened, the patient, during a tranquil
state of the circulation, feels little or no difficulty of respiration ;
but he is incapable of making the same corporeal efforts as other
persons without losing breath : to use a common phrase, he is
"short-winded." After a respite of a few minutes, however, he
recovers, and is, therefore, seldom deterred by this symptom from
prosecuting his accustomed avocations. Many, indeed, become so
habituated to a slight degree of dyspnoea that they deny its exist-
ence, even after ascending a staircase. The practitioner should
always judge for himself by counting the pulse and respirations
after a muscular effort, and ascertaining whether they are accele-
rated beyond the natural degree.
I have frequently observed that an individual who pants on first
setting out on a walk, is capable of sustaining great exertions with-
out inconvenience when he gets warm, and the blood is freely deter-
mined to the surface.
When the disease has proceeded so far as to occasion external
dropsy, and sero-sanguineous congestion of the lungs, more or less
dyspnoea becomes almost habitual, and it sometimes occurs, conjoin-
ed with palpitation, in paroxysms of excessive severity, especially
in asthmatic subjects. From this period, indeed, the symptoms are
a compound of those of hypertrophy and those of an obstructed
circulation, the latter of which are more particularly considered in
the article Dilatation. The cause of obstruction has been explained
at page 254.
3. Cough. — There is generally little or no cough in the early
stages, biU it occasionally supervenes when dropsy appears, in con-
nection with which, more or less sanguineous and serous congestion
almost invariably takes place in the lungs, and gives rise to the
SIGNS AND DIAGNOSIS OF HYPERTROPHY. 265
symptoms in question. The congh is seldom considerable unless
the patient is subject to chronic bronchitis, either in the dry or
pituitary form.
4. Hcemoptysis. — This is the result of a too impetuous discharge
of blood into the capillary system. It is of rare occurrence, for
the same reasons assigned above (p. 261).
5. Pulse. — The pulse in hypertrophy of the left ventricle under-
goes, from valvular and other lesions, a variety of modifications
which disguise its real nature. It must, therefore, be studied in
cases totally exempt from complication. In such, it is almost inva-
riably regular, and bears strict relations in strength and size to the
thickness and capacity of the left ventricle. Thus, in simple hyper-
trophy, it is stronger, fuller, and more tense than natural : it swells
gradually and powerfully, expands largely, dwells long under the
finger, and in anaemic subjects, (but no others.) is sometimes accom-
panied with a thrill or vibration. These characters are still more
marked in hypertrophy with dilatation, so long as the hypertrophy
is predominant; but when the dilatation has proceeded so far as to
diminish the contractile power of the muscular fibres, the pulse,
though still full and sustained, is soft and compressible. In hyper-
trophy with contraction of the cavity, it is tense, but small, expand-
ing little under the finger ; and, if the contraction be great, it loses
its tension and becomes weak as well as small, from the insufficient
quantity of blood propelled into the arteries.
The strength, largeness, and tense prolongation of the pulse of
hypertrophy with dilatation, are often so remarkable, that, from this
sign alone, the practitioner may often make a successful conjecture at
the nature of the disease ; for inflammation only can impart similar
strength, and comatose affections, similar prolongation.
The pulses of hypertrophy and hypertrophy with dilatation now
described, may present exceptions ; for depression or exhaustion of
the nervous system, whether from the advanced stage of the disease,
or. from accidental, debilitating causes of any kind, may so neutral-
ize the contractile energy of the heart as to enfeeble the pulse. Thus,
according to my observation, it is an ordinary occurrence for a pulse,
which was large, strong, and regular in the early stages, to become
more or less small weak, and even irregular before death. I have
also repeatedly noticed that a hypertrophic pulse has become perma-
nently small and weak from the date of an apoplectic or paralytic
attack, which has debilitated the general system and even put a
period to previous headaches. The pulse may also become tempo-
rarily small and weak during severe attacks of palpitation and
dyspnoea, by which the heart is gorged and rendered incapable of
freely expelling its contents. I have observed the same to result
from great plethora, the pulse becoming full and strong after
moderate bleeding. These exceptions, being referable to obvious
causes, confirm the general rule.1
1 Dr. Graves found, in five or six cases of "very great hypertrophy with
266 HOPE ON DISEASES OF THE HEART.
6. Affections of the Head. — These exist in a large proportion,
but, not in all. The patient complains of a " rushing of blood to
the head" on making any corporeal effort or stooping; of more or
less intense throbbing anjj lancinating headaches, aggravated by
the recumbent position, and especially by the act either of sud-
denly lying down or rising up; of vertigo, tinnitus aurium,
scintillations and other visual illusions ; and sometimes of a
lethargic somnolency, which so completely subdues the faculties
both of the mind and the body, as utterly to incapacitate him
for every species of exertion. These symptoms, if not relieved, are
apt to terminate in palsy, apoplexy, or inflammation of the brain.
From these catastrophes the patient is occasionally preserved by
the opportune occurrence of epistaxis, to which, happily, he has
an increased predisposition. From the circulation in the early
stages of hypertrophy being active in the eye, this organ is often
bright and sparkling, and sometimes vascular or blood-shot.
7. Complexion. — The effect of hypertrophy is to heighten the
colour so long as the capillary circulation continues unembarrassed,
but afterwards to diminish and change it. Every individual,
however, does not acquire a florid colour. Whether he acquires it
or not, depends, in fact, upon his original complexion, the series of
changes being different in those who are naturally florid, and those
who are pale. In the former, the colour becomes remarkably vivid,
and, being generally accompanied with plethoric turgescence, it gives
the aspect of health and good condition. But when the capillary
circulation begins to labour, the red changes into a purplish patch
on the cheeks ; the nose and lips become more or less purple, violet,
or livid, and the intermediate skin becomes pale and sallow. In
great hypertrophy with dilatation, the purple and violet colours are
sometimes of the deepest dye. In those, on the contrary, who are
naturally devoid of colour, hypertrophy either does not excite it at
all, or merely increases, in a slight degree, the general vascularity
of the face. This vanishes entirely when the capillaries become
obstructed, and is superseded by universal cadaverous paleness and
sallowness, extending sometimes even to the lips. They, however,
are generally somewhat livid. These distinctions have been wholly
overlooked by authors, who have created much confusion by assign-
ing a red face to all hypertrophic subjects without distinction.
dilatation," that the pulse was not accelerated, (after the first quarter of a
minute,) by substituting the erect or sitting, for the horizontal position, as it
is in health, and, still more, in all diseases of debility, — the change amount-
ing to from 6 to L5 beats per minute in the healthy, and from 30 to 50 in the
debilitated. " It would be premature," says he, " to inquire into the cause of
this phenomenon, but it immediately suggests itself to the mind, that it de-
pends on the increased strength and energy of the left ventricle when in a
state of hypertrophy, and which, in a great measure, place its contractions,
as it were, beyond the influence of those causes which, in other diseases,
attended with debility, and even in many persons in health, enable a change
of posture to produce so remarkable an alteration in the frequency of the
pulse" (Dub. Hosp. Rep. vol. v. p. 567). I imagine that the cause of the
frequency is simply, the greater hydrostatic pressure on the heart in the erect
position.
SIGNS AND DIAGNOSIS OF HYPERTROPHY. 267
8. Serous Infiltration.— This, for reasons already assigned, (p.
255,) seldom appears before the hypertrophy is very considerable,
or becomes conjoined with enfeebling dilatation. It occasionally
shows itself first in the face : a circumstance attributable to the
great number and size of the cerebral arteries, and to the force with
which the blood is injected into them, in consequence of their prox-
imity to the heart. More commonly, however, it begins in the ankles,
and gradually becomes universal. With dropsy, supervene, in a
greater or less degree, all the other symptoms of an obstructed cir-
culation.
9. Angina Cordis.— In a great number of cases of hypertrophy,
I have found patients complain of a dull, though severe aching
pain in the region of the heart, usually extending towards the
shoulder and down the inside of the arm to the elbow or below.
It is generally aggravated by exertion, especially walking up-hill
or against the wind. It appears to me to be dependent upon over-
tension of the heart, as I have generally found it cease or greatly
diminish after one or two abstractions of §vi or viii of blood, and
a few purgatives. Angina, however, is not an essential symptom
either of hypertrophy, or of any other disease of the heart, though
there is no form which I have not known it to accompany. Slight
degrees are perfectly common in nervous and hysterical subjects,
wholly exempt from organic disease. The old writers erroneously
supposed it to be restricted to ossifications. It is true that, in
these, it is apt to attain its highest degree of agonizing intensity.
Signs of Hypertrophy of the Right Ventricle. — Hypertrophy
of the right ventricle produces, according to Corvisart, a greater
difficulty of respiration, and a deeper colour of the face, than is
produced by the same affection in the left ventricle. I have not
been able to verify this. Corvisart was possibly mistaken, from
his imperfect acquaintance with valvular disease, especially mitral
regurgitation, which probably occasioned, not only the dyspnoea
and deep colour, but the hypertrophy itself, as explained above
at p. 251. Another alleged sign is, the more frequent expectora-
tion of pure arterial blood. This is very questionable.
The only signs of value besides the physical, (viz. increased
impulse and dulness on percussion under the lower portion of the
sternum,) are, 1. absence of the strong, large, and prolonged pulse
of hypertrophy of the left ventricle, in the few cases in which the
right alone is hypertrophous : 2. turgescence of the external ju-
gular veins accompanied by pulsation synchronous with that of
the arteries. This was broached by Lancisi as a sign of "aneu-
rism," i. e. hypertrophy with dilatation, of the right ventricle.
Though rejected by Corvisart, — in my opinion on insufficient
grounds, it is approved of by Laennec. who found it to exist in
every case of rather considerable hypertrophy of the right ven-
tricle, and never in that of the left unless the right was simulta-
neously affected (Laennec de l'Auscult. torn. ii. p. 505). I have
rarely known it to be absent in cases where dilatation was con-
268 HOPE ON DISEASES OF THE HEART.
joined with hypertrophy of the right ventricle. Of such cases,
therefore, I regard it as one of the best general signs, though, after
all, it is but an equivocal one.
The explanation of the phenomenon offered by MM. Bertin and
Bouillaud, and by the latter in his subsequent work, (ii. p. 449,)
appears unsatisfactory. "The jugular or venous pulse," says he,
" is seen in those cases only in which dilatation accompanies
hypertrophy, and in which the auriculo-ventricular orifice, being
greatly enlarged, is no longer completely closed by its valve : thence
ensues a regurgitation of blood into the great veins during the
contraction of the right ventricle." Hypertrophy with dilatation
has certainly, though not always, the effect of enlarging the auri-
culo-ventricular orifice; but the valve in most instances expands in
a corresponding degree ; as I have repeatedly found. I apprehend,
therefore, that The venous pulsation, in the cases where I have ob-
served it to exist, was not attributable to regurgitation : in substan-
tiation of which opinion I may say, that regurgitation would be
attended with a bellows or other such sound: this sound, however,
is not found to be a concomitant of jugular pulsation. Is the rationale
of the phenomenon as follows? namely, as the ventricle, when
hypertrophous, contracts with augmented power, the recoil of the
tricuspid valve is preternaturally impetuous : hence, the column of
blood in the act of descending into the ventricle, is repelled with
such an increase of force, that its impulse is propagated as far back
as the jugular veins. This effect will be more considerable when
the orifice and valve are enlarged, because the quantity of fluid
repelled will be greater. The effect will also be favoured by con-
gestion of the great veins, (a state which generally accompanies
hypertrophy with dilatation of the right ventricle,) because, when
congested, they are more tense, unyielding tubes, and more readily
transmit an impulse.
But the jugular pulsation is double : a weaker pulsation precedes
that occasioned by the ventricular systole. The weaker is occa-
sioned by the auricular systole, and the mechanism of its formation
I conceive to be this : at the time that the auricle contracts, the
ventricle is in a state of moderate or natural fulness: it therefore
offers a certain degree of resistance to the ingress of more blood
from the auricle ; consequently, so much of the blood compressed
by the auricular systole as cannot get forward into the ventricle, is
forced back into the veins and causes their pulsation. Some con-
tend that the auricle occasions no jugular pulsation, founding their
opinion on the assumption that the ventricle is empty at the mo-
ment that the auricle contracts, and that, therefore, the whole of
the auricular blood must descend into the .ventricle. Such an
assumption, however, according to the evidence adduced in the
first part of this work, (p. 45, 41, and 88,) is incorrect.
A difficulty has sometimes been experienced in distinguishing
jugular pulsation from that of the carotid arteries. Error may
easily be avoided by observing that the jugular pulsation is con-
SIGNS AND DIAGNOSIS OF HYPERTROPHY. 269
fined to the lower part of the neck, and is far on the humeral side
of the carotid. The pulsations of this artery, on the contrary,
extend as high as the angle of the jaw, and in the direction of the
anterior margin of the sterno-cleido mastoideus muscle.
The jugular turgescence, moreover, disappears in some degree
during inspiration and reappears on expiration : which movements,
therefore, must not be confounded with the pulsations answering
to the systole of the ventricle.
General Signs of Hyper trophy of the Auricles.
There are none that are distinguishable from those of disease
or obstruction in the corresponding ventricle or orifice, to which
the hypertrophy of the auricles owes its origin. The detection of
hypertrophy of the auricle is of little importance, as it is the cause
that produced it, which is the source of danger.
Physical Signs of Hypertrophy.1
Impulse. — According to Laennec, the impulse is best appre-
ciated by the ear applied to the stethoscope. I participate in this
opinion ; for I continually meet with cases in which an applica-
tion of the hand would not authorise an assertion that there was
an increase of impulse, yet an application of the stethoscope renders
that increase distinctly appreciable. It was, perhaps, to these cases
of slight increase of impulse that Laennec alluded, when he said
that the application of the hand was a very fallacious mode of
appreciating the impulse. This mode, however, is far from useless
in examining great degrees of impulse. It is my own invariable
habit to begin an examination by application of the hand ; whence
I acquire a general idea of the extent and strength of the impulse,-
and a knowledge of the precise spot where it is strongest, and
where, consequently, it is best to apply the stethoscope. A good
idea of the heaving nature of the impulse, is acquired by watching
the rise and fall either of one's own hand applied to the part, or
the head of an explorer resting on the stethoscope. The immediate
application of the ear is, in my opinion, the least delicate mode of
estimating the impulse, as slight degrees are not perceptible by it,
and, in high degrees, it is unneccessary, as then, even the hand
alone will generally answer every purpose. However, M. Bouil-
laud says, "in a good number of cases, (I do not say in all,) the
immediate application of the ear is preferable to the use of the
cylinder in appreciating the shock of the heart." (Traite i. 140,
note.) I do not understand to what class of cases he alludes.
In simple hypertrophy, "the impulse," says Laennec, "com-
municated by the stethoscope while the patient is in a calm state,
is usually so strong as distinctly to raise the head of the observer,
and sometimes even sufficient to produce a shock disagreeable to
1 For the rationale of the impulse and sounds in the several varieties of
hypertrophy, the reader is referred to p. 92,
270 HOPE ON DISEASES OF THE HEART.
the ear. The greater the hypertrophy, the longer this heaving
takes for its performance. When the malady exists in a great
degree, we evidently perceive that the heaving takes place with a
gradual progression; it seems as though the heart swelled and
applied itself to the parietes of the chest, at first by a single point,
then by its whole surface, and finally sank back in a sudden man-
ner." This sinking back did not sufficiently arrest the attention of
Laennec. In the first edition of this work, I called attention to it,
as a new sign of hypertrophy, under the name of the back-stroke :
but the term diastolic impulse, which I now propose to use, is a
more descriptive appellation. It is occasioned by the diastole of
the ventricles, during which action the heart sinks back from the
walls of the chest, and this sinking back terminates in a jog or
shock, occasioned by the refilling of the ventricles, and constituting
the diastolic impulse in question. It is stronger, cceteris paribus,
in proportion as the heart is thicker and more capacious. Accord-
ingly, I have found it strongest in hypertrophy with dilatation, but
it may also be very considerable in simple hypertrophy. In the
heaithy heart it is not perceptible, neither is it in dilatation without
hypertrophy.1
A strong, slowly heaving impulse, then, is the principal sign of
simple hypertrophy; and the affection maybe known to be greater,
when the impulse is followed by a diastolic impulse. Both these
signs exist in hypertrophy with contraction, but in a less degree,
and the diastolic impulse may be absent if the hypertrophy is not
great.
In simple hypertrophy and that with contraction, the impulse is
seldom perceptible much beyond the praecordial region, except
during attacks of palpitation.
In estimating the impulse in this and every other form of dis-
ease, it is to be taken into account that, other circumstances being
equal, the impulse is more perceptible in proportion as the walls of
1 M. Bouillaud thinks that the back-shock or diastolic impulse was new,
(non moins neuf qu' interessant,) when he wrote on it (Traite, i. p. 148).
In this idea, he does not, I think, do full justice even to M. Laennec. " M.
Laennec," says he, " teaches that the impulse of the heart is only percepti-
ble at the moment of the ventricular systole: consequently, that it is unique,
simple, and not double." But Laennec applies the expression " s'affaisse
lout-d-coup" to the diastole in hypertrophy; whence it appears to me that
he was not wholly a stranger to the diastolic impulse. But though Laennec
only glanced at the phenomenon, it was fully described by myself, as seen
above, several years before M. Bouillaud published. I must entirely dissent
from him when he adds, " a phenomenon still more curious, is, that for one
systolic impulse there may be two diastolic impulses," (p. 147,) the first or
systolic impulse only being accompanied with a radial pulse. He cites a
case in exemplification. But I have already shown \p. 90) that he has mis-
taken the entire subject. These intermediate impulses without pulse, are
not diastoles, but systoles, of the ventricles, as proved by their being inva-
riably attended with a first sound or click of the auricular valves, and often
with a barely perceptible pulse. This is only an offset of the same error,
which led him to ascribe the intermediate sounds to auricular contractions.
SIGNS AND DIAGNOSIS OF HYPERTROPHY. 271
the chest are thinner. Thus, it is the most distinct in the emaciated,
and in children ; whereas, in very stent and muscular subjects, it
may be barely perceptible.
In hypertrophy with dilatation, the signs are a compound of
those of hypertrophy and those of dilatation. The contraction of
the ventricles can easily be felt by the hand applied to the prascor-
dial region, and we find, especially during palpitation, smart, vio-
lent shocks, which strongly repel the hand. In extreme cases. I
have known the extent of these almost equal that of the expanded
hand. If we attentively examine the patient when most calm, we
see that not only his whole chest and the pit of the stomach, but
his head, his limbs and even the bed-clothes, are strongly shaken
at each contraction of the heart. The pulsations of the carotids,
the radials, and the other superficial arteries, are often visible.
The impulse of the heart can sometimes be distinctly felt as high
as the clavicle on the left side of the thorax, and sometimes even on
the left side of the back, especially in meagre subjects and children.
["The situation of the dullness on percussion, and of the impulse, will
vary according to the form of the dilated hypertrophy and other circumstan-
ces which affect the position of the organ. In elongated enlargement the
impulse is generally felt below its usual spot, between the fifth and sixth
ribs, down to the seventh oreighth ; and I have even felt it in the abdomen,
below the margin of the ribs. The dullness reaches from that part upwards
to the sternum. But constant, or even occasional distention of the abdomen,
by any cause, which prevents the descent of the diaphragm, will make the
enlarged heart take another position, by which its apex extends further to
the left, and the dullness on percussion reaches from that point to the ster-
num, occupying the whole intra-mammary, and perhaps part of the mam-
mary region. The same position of the heart, thus more horizontal than
natural, may, perhaps, also be caused, as Dr. Hope has pointed out, by ad-
hesion of the pericardium, which prevents the organ from enlarging down-
wards. Enlargement of the liver, distention of the stomach or colon, and
dropsical effusions in the abdomen, are the most frequent causes of this
lateral direction which enlargement of the heart often takes. Similar causes
may also determine the displacement to be outwards, against the thoracic
walls, occasioning them to project to the left of the sternum, in the manner
described by Bouillaud. This is most remarkable in children, and in young
persons with narrow chests. When the enlargement is more transverse or
globular, the dullness on percussion, and the impulse, are higher, indepen-
dently of the position of the diaphragm ; and this is particularly the case
when the right ventricle is also enlarged/' — C. J. B. Williams. — P.]
In hypertrophy with a predominance of dilatation, the impulse
is ordinarily not considerable ; but it becomes very marked during
palpitation, especially if accompanied with fever, and it has a very
different character from that occasioned by simple hypertrophy.
The beats, as well described by Laennec, are strong, hard, and
produce a shock analogous to the blow of a hammer ; but the blow
seems to strike a small space, it expends itself, as it were, on the
thoracic parietes, and does not communicate to the head a heaving
proportioned to its force : it differs, in short, from the impulse occa-
sioned by great hypertrophy, in the circumstance that, in the latter,
the ventricles in a distended state, seem to heave with their whole
272 HOPE ON DISEASES OP THE HEART.
length against the thoracic parietes, which yield to the effort ;
while, in the former case, the point only of the heart seems to strike
the'parietes with a sharp, smart, accurately circumscribed blow,
only capable of producing a sort of concussion, rather than a real
heaving.
When the impulse is increased on one side only of the precor-
dial region, that is, under the inferior part of the sternum, for the
right side, and between the cartilages of the fifth and seventh left
rites, for the left, we infer that the corresponding ventricle only is
affected: and when it is increased on both sides, we conclude that
both are affected, which is the more common case.
[Under ordinary circumstances, the apex of the left ventricle is the only-
part of it which touches the parietes of the chest: but if the left side of the
heart becomes hypertrophous or enlarged, whilst the right remains of its
usual size, other portions of the surface of the left ventricle are brought in
contact with the ribs, and the impulse of this ventricle will then be felt over
an unusual extent, sometimes even as far as the edge of the sternum.
Again, should the right ventricle be also enlarged it will keep the left ven-
tricle to the left, remove it from the walls of the chest, and thus prevent the
communication of its impulse to the observer. Hence the reason that
hypertrophied hearts do not always beat with the force that might be anti-
cipated. " The position of the whole heart and its compartments being
changeable," in disease, the relative situation of the several parts in refer-
ence to the ribs may be entirely different from that of a state of health. But
the character of the sounds which are heard over the right and left ven-
tricles will indicate their positions ; " and if an hypertrophied left ventricle
encroaches on the region of the right, we may still know that it is the left,
by finding a different kind of sound and impulse to the right of it, and no
other kind to the left 5" and so with regard to displacement of the left ven-
tricle by the right.
In cases also where the impulse of the left hypertrophied ventricle is
masked by removal from the parietes of the chest as indicated above, its
force may be estimated by the strength of the pulse at the carotid arteries,
provided, that there be no aneurism of the aorta. But, on the other hand,
although the cardiac impulse may be strong at the precordial region, it
should always be borne in mind that, that impulse in itself is not evidence
of hypertrophy. A consolidated or hepatised lung, pleuritic effusions,
tumours, aneurism of the thoracic aorta, &c, may push the heart forward so
as greatly to increase the impulse, even when no hypertrophy exists.
A heart enlarged by a deposit of fat around it, yields, says Williams, an
obtuse systotic sound as in hypertrophy ; but the arterial pulse and cardiac
impulse are weaker, and the dulness is more at the sternum or middle
portion of the heart. — P.]
In hypertrophy, and hypertrophy with dilatation, free from val-
vular disease, the beats of the heart, even during palpitation, are
rarely irregular in the early stages of the disease, while the patient's
general strength continues little impaired; but I have often met
with temporary irregularity during excessive dyspnoea, and with
permanent intermission when the strength and vital powers failed
in the late stages, especially on the approach of dissolution. Ner-
vous and dyspeptic intermission may, of course, affect a patient
labouring under hypertrophy ; but this is accidental, and not a part
of the disease.
SIGNS AND DIAGNOSIS OF HYPERTROPHY. 273
The impulse of the heart is diminished by loss of blood, diarrhoea,
any exhausting disease, rigid and long-continued abstinence, and,
in general, by all the causes capable of producing debility. Conse-
quently, a moderate hypertrophy might, without due care, be over-
looked in a patient under any of these circumstances. It has
frequently occurred to me to notice, that patients, cured of hyper-
trophy by tranquillising means, have eventually disbelieved that
they had ever laboured under it — especially when biassed by^he
opinion of others.
The impulse of the heart, moreover, [is often masked by the ex-
istence of pulmonary emphysema over the precordial region, — P.]
and it occasionally ceases entirely, or becomes a mere oppressed
struggle, (even in cases of very marked hypertrophy,) when there
supervenes intense dyspnoea referable to some affection of the lungs,
especially peripneumony, pleurisy, oedema of the lungs, asthma,
and the congestions which form during the last moments of life.
The sounds likewise diminish : no inferences, therefore, should be
drawn from an exploration made under such circumstances.
Sounds. — Hypertrophy has the effect of deadening the sounds of
the heart. In simple hypertrophy, the first sound, i. c. that pro-
duced by the ventricular contraction, is duller and more prolonged
than natural, in proportion as the hypertrophy is more considera-
ble. When the hypertrophy exists in an extreme degree, the first
sound becomes nearly extinct: Laennec says, wholly ; but I have
never found it so. It may always, I think, be heard by placing the
stethoscope on that part of the ventricles which is in contact with
the walls; namely, about the apex. The second sound, i. e. that
produced by the sigmoid valves during the ventricular diastole, is
very feeble ; in extreme cases, says Laennec, it is scarcely percepti-
ble; but I have always found it distinct immediately over the sig-
moid valves, and thence up the courses of the aorta and pulmonary
artery. The interval of repose is shorter than natural, in conse-
quence of the first sound being longer. Both sounds are propor-
tionably weaker in hypertrophy with contraction. In most cases
of both these forms of hypertrophy, the first sound can scarcely be
heard under the left clavicle and at the upper part of the sternum,
but the second generally can.
Each sound of the heart, though essentially one. consists of the
sounds of the two sides united. This is proved by a bellows-mur-
mur in the left prcecordial region being audible in the right, and
vice versa. It does not follow, therefore, that when one ventricle
only is hypertrophous, the sound of the heart in general should be
very limited in its range; for that of the other ventricle will be
heard over an extent proportioned to its intensity, though not quite
so far as when strengthened by its fellow. On the other hand, a
morbidly increased sound of one ventricle, as by dilatation or a
bellows-murmur, will be heard alone at points beyond the range of
the natural sound of the other or healthy ventricle. Accordingly,
10— f 18 hope
274 HOPE ON DISEASES OF THE HEART.
it is only in hypertrophy of both ventricles that we must expect to
find the sounds confined within very narrow limits.
The second sound is more audible than the first from the semi-
lunar valves, up the sternum, to the clavicles. This remark applies
both to hypertrophy and to the healthy state. The reason is, that,
as the sound is created by the semilunar valves, it is transmitted
along the aorta and pulmonary artery, (Exp. on the sounds, Obs.
l^ap. 55,) and likewise through the sternum. For the same reason,
the sound is often distinct at the clavicles when it is drowned in
the precordial region by a valvular, or pericardiac murmur, or a
pulmonary rale.
In hypertrophy with dilatation the sounds are increased to their
maximum, being louder than in any other disease of the heart, es-
pecially during palpitation. The first is, as it were, a compound
of the sound of dilatation and that of hypertrophy : namely, from
dilatation it derives a loud, abrupt commencement, and from hy-
pertrophy, a prolonged termination, as explained at p. 89 and 94.
The second sound, though not changed in character, is louder than
natural. These sounds may frequently be heard over the whole
chest both posteriorly and anteriorly, especially in children and
meagre subjects.
In hypertrophy with a predominance of dilatation^ the first
sound is not so loud as in the preceding variety, nor has it a pro-
longed termination, but is short and smart like the second, being
produced almost entirely, I conceive, by the extension of the auri-
cular valves.1 The second sound is not altered, but. is a degree
louder than natural, from the quickness of the ventricular diastole.
The sounds of the heart in every form of hypertrophy, may be
diminished by the same causes that diminish the impulse. They
are specified at p. 273.
In a very few cases of great hypertrophy with dilatation, a slight,
soft murmur in the aortic orifice accompanies the first sound, as
already explained at p. 117. It is, I think, occasioned by the
anaemia, which frequently supervenes in the last stage of this
disease.
Resonance* of the precordial region on percussion is deficient in
simple hypertrophy i if the heart is considerably enlarged ; but, as
hypertrophy with dilatation is the disease in which the organ at-
tains the greatest volume, it is that in which resonance is most fre-
quently and most extensively deficient. The line of dulness where
the heart comes in contact with the walls, may be traced with great
precision ; and it often forms a circle of two, three, and occasionally
four inches in diameter. (See Percussion, p. 33.) In all cases of
considerable enlargement, the dulness as well as the impulse, are
[l The incorrectness of this hypothesis has been shown in the discussion
on the sounds of the heart in the first part of this work. — P.]
2 See much valuable information on this subject in the " Procede Opera-
toire" of M. Piorri. Paris, 1830. p. 112, et seq.
PROGRESS AND TERMINATION OF HYPERTROPHY. 275
lower down than natural, except in adhesion of the pericardium ;
for the heart is then more or less braced up by the adhesion.
Emphysema counteracts dulness, in consequence of the Lang's
advancing in front of the heart. Percussion should then be made
during the state of expiration, and while the patient leans forward.
I have known double emphysema depress the heart completely into
the epigastrium.
Prominence of the precordial region. — This was noticed as a
sign of hypertrophy by the writer, in the first edition of this work,
p. 579, 467, 130, &c. M. Bouillaud has more recently observed the
same: he says, '-The prominence of the precordial region had not
yet been noticed, to my knowledge, by any of the authors who have
published on the diseases of the heart:' (Traite, ii. 444, and i. 150).
It is a sign of only secondary importance, since it does not exist till
the hypertrophy is very considerable, when it is sufficiently indi-
cated by other signs.
[When the prominence of the precordial region is caused by hypertrophy,
the respiration is still observed at the elevated space ; but in the raised por-
tion of the chest caused by the effusion attendant upon pericarditis into the
pericardium, the respiration is absent, owing to the displacement of the
lung. Hence the presence or absence of the respiratory murmur, at the point
indicated, is of essential importance in forming the diagnosis of the cardiac
affect ion. — P.]
SECTION VI.— Progress, terminations and prognosis of Hypertrophy.
Progress and termination of Hyper trophy. — Hypertrophy, while
moderate and not complicated with any mechanical impediment to
the circulation, is productive of very little inconvenience. This is
especially true with respect to children. In them, the heart is
naturally larger in proportion than in adults; and in many this
amounts to a very considerable degree of hypertrophy with dilata-
tion, accompanied with greatly increased impulse and sound ; yet
the general symptoms manifested by such are often scarcely appre-
ciable, and the increased action itself subsides towards the period of
puberty by the establishment of a more correct proportion and
equilibrium between the heart and the system.
At the adult age also, and during the whole period of manhood,
an individual of an otherwise sound and vigorous constitution may
be affected with hypertrophy to a moderate extent, without expe-
riencing any sensible deterioration of the general health, (with the
exception of being more liable than others to phlogistic and cerebral
affections,) or any diminution of muscular force and activity: and
if his habits with respect to diet and exercise be moderate, he may
pass a long series of years, and even attain the extreme period of
senility, without being conscious that he is the subject of organic
disease. The only general signs denoting the existence of the
malady, will be, perhaps, a little shortness of breath on exertion,
and occasional feelings of slight palpitation. Amongst the labour-
18*
276 HOPE ON DISEASES OF THE HEART.
ing classes these symptoms, even in a considerable degree, are so
little- regarded, that their presence is often disavowed by the patient,
though manifest to the physician. I recently saw an athletic, hard-
working man, weighing, according to his own account, not less
than twenty stone, with enormous hypertrophy and dilatation, who
assured me that " his palpitation had quite left him for a month,"
yet the heart was acting with a violence that was truly astonishing.
If, however, an individual affected with hypertrophy abandon
himself to intemperate living, or engage in occupations requiring
great corporeal exertion, he rarely fails to bring on either apoplexy,
palsy, or an aggravated state of the hypertrophy, which, if not
removed by speedy and judicious treatment, embitters the remain-
der of his existence, as well as curtails its span.
The celerity with which these accidents are induced, depends on
circumstances. In general, the progress of hypertrophy is very
slow and gradual, but in some cases it is rapid: in several instances
I have known it terminate fatally within a year from its commence-
ment.
The circumstances occasioning these variations are connected
with, 1, the form of the disease; 2, its complications; 3, the nature
and intensity of the external exciting causes ; and, 4, the constitu-
tion of the patient.
It is of the utmost importance that the practitioner be able to
form some estimate of the influence of these circumstances; for it
is by this means only that he can foresee the course of the disease,
and direct his treatment with judgment and decision. It may be
useful, therefore, to enlarge a little on this subject.
1. The progress and termination of hypertrophy are influenced
by the form of the disease. Simple hypertrophy is more apt than
any other form to induce apoplexy or palsy vhile the patient is
apparently in perfect health. This is to be accounted for by its
tendency to create plethora, while, at the same time, it does not
incapacitate the patient for active corporeal exercise, and the plea-
sures of the table. If a premature death does not occur from apo-
plexy or palsy, simple hypertrophy runs a more chronic course
than any other form of the disease.
Hypertrophy with dilatation, especially if great, is a far more
harassing, dangerous, and, if I may be allowed the term, acute
affection than the preceding. All its symptoms are most violent,
and its course is more rapid. It is somewhat less apt to produce
unexpected attacks of apoplexy ; probably because the greater
dyspnoea which it occasions deters the patient from violent exer-
cise and high living. When once general dropsy appears, and
shows a decided disposition to recur again -and again, notwith-
standing judicious treatment, the malady hurries with an uninter-
rupted course to its fatal termination.
2. The progress and termination of hypertrophy are influenced
by its complications. When hypertrophy is connected with con-
traction of an orifice, regurgitation through a valve, disease of the
PROGRESS AND TERMINATION OF HYPERTROPHY. 277
ascending aorta or arch, or any other material obstacle to the
course of the blood, the symptoms are greatly aggravated. por?
in the first place, in consequence of that obstacle, the hypertrophy
proceeds to a greater extent ; and, secondly, the violent struggles of
the heart to surmount the obstacle, subvert the general balance of
the circulation. To speak more explicitly, suppose the obstacle to
be situated in the aortic orifice. While the left ventricle is palpi-
tating to disgorge itself through the contracted aperture, the right,
acting in concert with it, deluges the lungs with an inordinate
quantity of blood ; whence ensues a paroxysm of dyspnoea : next,
in consequence of the pressure of blood through the lungs, the
supply to the left ventricle is increased : this ventricle, therefore,
instead of relieving its own engorgement by palpitation, only ag-
gravates it, and the fit does not subside until either the heart be-
comes gradually exhausted by its own efforts, or (what is more
common) until the internal congestion is relieved by determination
to the surface, or a copious discharge of watery mucus from the
lungs. The most violent paroxysms of palpitation and dyspnoea
that I have witnessed, have occurred in the particular complication
described, that is, in hypertrophy with valvular disease. In other
cases, however, there may exist a greater feeling of suffocation, as
will hereafter be explained in the chapters on diseases of the valves,
and on polypi.
Adhesion of the pericardium, which rarely fails to produce hy-
pertrophy with dilatation, is an extremely formidable complication
of this malady. It greatly aggravates all the symptoms, and acce-
lerates the fatal event. It is not unusual for this to take place
within the period of a year, and I have known it occur in nine
months. I entertain little doubt that this rapid course of the ma-
lady is. in part, referable to the injury done to the muscular sub-
stance by inflammation propagated to it from the pericardium ; for
it has already been shown (p. 248) that inflammation is a cause of
hypertrophy, and it will hereafter appear that it may also occasion
softening. For the same reasons, valvular disease resulting from
endocarditis, is in general a more serious complication of hyper-
trophy, than when it steals on gradually from causes independent
of inflammation. It is scarcely necessary to add, that the worst
cases of adhesion of the pericardium and valvular disease, are most
commonly those which result from rheumatic inflammation.
Febrile or inflammatory complaints supervening upon an ad-
vanced degree of hypertrophy, exasperate the malady in a surpris-
ing manner, so as not nn frequently to carry off the patient in the
course of a few days. The effect seems to be produced by the
febrile excitement keeping up, as it were, a perpetual fit of palpita-
tion and embarrassment of the circulation, which the constitution
cannot support beyond a brief period. Peripneumony and exten-
sive vesicular bronchitis have pre-eminently this effect : apparently
because they not only excite the heart, but obstruct the circulation
through the lungs.
278 HOPE ON DISEASES OP THE HEART.
3. The progress and termination of hypertrophy are influenced
by the nature and intensity of the external exciting causes.
The principal of these are, over-exertion, excesses at table, and
mental perturbation, the latter of which, though not strictly exter-
nal, may be ranged under this head. The effect of these requires
no explanation ; but it may be said, that the injurious influence of
over-eating and drinking is greatest in simple hypertrophy, because
it generates plethora and increases the tendency to apoplexy; while
over-exercise and intemperance are more prejudicial in hypertrophy
with dilatation, because they increase the dilatation, which is the
more dangerous part of the disease.
4. The progress and termination of hypertrophy are influenced
in a remarkable degree by the constitution of the patient. The
robust resist its encroachments much longer than those who are
delicate and effeminate ; and if the former, either from bad air and
diet, from disease, or from age, become unhealthy, anaemic, ema-
ciated, and feeble, they are rendered much more susceptible of the
effects of the disease. Excessive blood-letting, on Albertini and
Valsalva's plan, for the cure of hypertrophy, produces the same
effect, and thus defeats its own object. It is for this reason that I
have proposed another mode of blood-letting, &c, founded on a
different principle, as will presently be explained.
Prognosis. — The general prognosis is favourable in the early,
and unfavourable in the advanced stages of the disease, when
dropsy has appeared and obstinately recurs. This is especially the
case in the aged, and in feeble, shattered constitutions. The par-
ticular prognosis must be founded on an estimate of the various
circumstances of each case, formed according to the above rules.
SECTION VII.— Treatment of Hypertrophy.
Before the introduction of auscultation, when practitioners could
not distinguish disease of the heart with any certainty, and seldom
before it was in an advanced stage, they generally considered it as
hopeless, and contented themselves with palliating urgent symp-
toms. Nor can this be a subject of surprise, for, in that stage, the
disease most frequently is hopeless so far as a cure is concerned.
But, since it has become possible, by the aid of auscultation and the
improved knowledge of general symptoms to which it has led, to de-
tect not only the slighter degrees of hypertrophy or dilatation, but
even the mere tendency to those affections ; and since it has been
fully proved that, in their early stages and sometimes even when
far advanced, they are within the resources of the curative art. the
practitioner would be wanting in the performance of his duty to his
patient were he not to aim at effecting a radical cure, rather than
content himself with merely palliating symptoms.
In the treatment, it is obvious that the first care should be, to
remove any known exciting cause of the malady, as violent exer-
cise, intemperance, mental excitement, (fee. It is equally obvious
TREATMENT OF HYPERTROPHY. 279
that, as this malady consists in an increased power and action of
the heart, blood-letting and other reducing and tranquillising means
are the appropriate remedies. Laennec strongly recommends that
they be employed, with courage and perseverance, on the plan of
Albertini and Valsalva. I cannot say that my own observation
leads me in the least degree to coincide with him in this opinion.
I shall first, therefore, give a sketch of the treatment alluded to, as
the sanction accorded to it by names of the highest authority ren-
ders it at least deserving of attentive consideration : and I shall
afterwards point out in what respects it appears to me to be objec-
tionable.
This treatment, according to M. Laennec. ought to be prose-
cuted in an energetic manner, especially at the commencement ;
and, in aiming to enfeeble the patient, we ought, says he, much
more to fear resting short of the mark, than exceeding it. We
should commence by abstracting blood as copiously as the patient
can support without falling into a state of sinking, and we should
repeat the operation every two, four, or eight days, until the palpi-
tation has ceased, and the heart no longer gives, under the stetho-
scope, more than a moderate impulse. We should, at the same
time, reduce to at least one half, the quantity of aliments which the
patient ordinarily takes, and diminish even this quantity, if he pre-
serve more muscular strength than suffices to take, step by step, a
walk of a few minutes in the garden. In a stout adult, Laennec
usually reduces the quantity to fourteen ounces a day, amongst
which he thinks there should be only two ounces of white animal
food. If the patient wish to take broth or milk, he counts four
ounces of these liquids for one of animal food. Wine ought to be
interdicted. When the patient has been about two months without
experiencing palpitation, and without strong impulse of the heart,
we may dispense with the bleedings, and somewhat diminish the
severity of the regimen, if habit has not yet been able in any de-
gree to reconcile the patient to it. But it is necessary to revert to
the same means, and with equal rigour, if in the sequel the impulse
of the heart increase again. We ought not to have confidence in
the cure until the expiration of a year of complete absence of all
the symptoms, and especially of all the physical signs, of hyper-
trophy. We must be afraid, pursues Laennec, of allowing our-
selves to be deceived by the perfect calm which blood-letting and
abstinence sometimes very promptly produce, especially if we have
commenced the treatment at a period wJien the hypertrophy was
already accompanied with extreme dyspnoea, with anasarca, and
with other symptoms which gave reason to fear an approaching
death.
If we begin the treatment of hypertrophy of the heart at a period
when it has already produced severe effects, particularly anasarca,
ascites, oedema of the lungs, and a very marked state of cachexy, we
ought not on that account to shrink from bleeding and abstinence.
To obtain success by the treatment described, it is necessary.
280 HOPE ON DISEASES OF THE HEART.
according to the same author, that the physician and the patient
arm themselves with almost equal patience and firmness; for it is
not more difficult for the latter to resign himself to a perpetual fast
and frequent blood-lettings than for the former to struggle daily
against the opposition of relations, friends, and the discouragements
which cannot fail to seize upon the patient in a treatment which
ought to continue at least several months, and sometimes to be
'prolonged during several consecutive years !
Such is the manner in which M. Laennec employs the treatment
of Albertini and Valsalva, and he states that he could cite a dozen
instances of cures of hypertrophy, either simple or with dilatation,
which have not been falsified for several years. One important
case, which he details, seems to prove that the treatment causes
atrophy of the heart; for the organ was remarkably less than the
fist of the subject, and was shrivelled or wrinkled in a longitudinal
direction.
My objections to the treatment described are founded on the
circumstance that, though I have invariably found the greatest
benefit to be derived, in the early stages, from sparing abstractions
of blood at intervals of two or three weeks or more, I have con-
stantly noticed that when, from the severity of the dyspncea and
palpitation in the advanced stages of the complaint, the practitioner
was induced, or thought himself compelled, to resort to frequent
bleedings at short intervals, the patient, though perhaps tempo-
rarily relieved, progressively declined from that moment, dropsy
increasing, and the paroxysms recurring more frequently and
with greater violence, until they eventually terminated, in his
destruction. Now, on comparing a patient under these circum-
stances with one under the influence of mere reaction from loss of
blood, (of which the experiments on dogs, described at p. 122,
present a graphic exemplification,) the analogy appears to me to be
very intimate. In both, the violence of the heart's action, so far
from being repressed by a reiteration of the blood-letting, is only
increased: in both the blood is, and necessarily must be, attenuated
and deteriorated, in consequence of the fibrinous petition and red
globules being replaced to a far greater extent than natural by
serum, which is more expeditiously regenerated; in both, in short,
there exists the state of anaemia, which is invariably attended with
a quick, jerking beat of the heart and arteries, palpitation and
breathlessness on exertion or excitement, and that disposition to
serous infiltration, which is, in popular language, called "dropsy
from debility."
These, then, are the causes of the patient's decline. The hyper-
trophic palpitation and tendency to dropsy are" aggravated by the
superaddition of anaemia.
Hence it appears that the indications in the treatment of hyper-
trophy, are, to diminish the quantity, without materially deterio-
rating the quality of the blood; and to do this in such a manner
as, without producing either reaction or anasmia, permanently to
TREATMENT OF HYPERTROPHY. 281
enfeeble the action of the heart and the energy of the circulation.
These indications have seemed to me to be fulfilled in the safest
and most effectual manner by the following means, the efficacy of
which I have tested on a large scale since I originally proposed
them in the first edition of this work.
Four, six or eight ounces of blood should be taken every two.
three, four, or six weeks, according to the age and strength of the
patient, so as merely to keep down palpitation, dyspnosa,and strong
impulse of the heart. If the head be much affected, the blood should
be drawn by cupping from the nape of the neck ; but it must be
clearly understood that, in case the cerebral symptoms amount to
an indication of apoplexy, or of inflammation of the brain, the
practitioner must not consider himself limited to the number of
ounces above stated, but must bleed according to the principles
which regulate the treatment of these affections.
In case of angina cordis, it might be supposed that cupping on
the praecordial region would be more efficacious in relieving the
pain, than bleeding from the arm; yet experience has shown me
that there is scarcely a choice between the two modes, the relief
seeming to result rather from the tension of the vascular system
being taken off, than from the counter-irritant effect of the cupping.
In very plethoric individuals, the pulse is sometimes small and
languid or oppressed, though there be a heaving, hypertrophic
impulse of the heart. Under these circumstances, strangers to
auscultation are often deterred from bleeding, by the impression
that the pulse is one of debility, and that the palpitation, dyspnoea,
angina, headache, &c. are nervous. The auscultator, however,
may bleed under the confident assurance that the pulse will rise,
and the other symptoms abate, when the tension of the vascular
system is removed by the depletion.
It might be imagined that the abstraction of so small a quantity
of blood as that above prescribed, would produce no effect whatever
on so formidable a disease as hypertrophy. Yet experience proves
the reverse: it produces a great effect, and I imagine this to be re-
ferable, not only to diminished tension of the vascular system, but
also to a slight reduction of the rich, stimulant quality of the blood ;
since I have not found it easy to produce an equivalent impression
by mere purgatives and hydragogues, though employed so actively
as to produce incomparably more annoyance to the patient.
The diet, in plethoric persons who rapidly reproduce rich blood,
should, for the first month or two, consist exclusively of white fish,
farinaceous articles, and vegetables: subsequently, a moderate pro-
portion of animal food may be allowed on alternate days. In ordi-
nary, average constitutions, the latter diet may be permitted from
the first. In weakly constitutions, and in advanced stages of the
disease, when anaemia has either already appeared, or would easily
be induced by an insufficiently nutritious diet, animal food should
be permitted daily. Whatever be the constitution, the patient
should never overload his stomach with an immoderate meal, nor
282 HOPE ON DISEASES OF THE HEART.
eat heartily during a state of exhaustion from fatigue or fasting, as
a degree of palpitation is almost sure to be the consequence. His
meals should be evenly distributed, and each should be light.
Though three meals, at intervals of five hours, are generally suffi-
cient, a fourth in a light form is better than immoderate indulgence
at any one. The food should be perfectly plain and simple ; since
dyspepsia, by exciting palpitation, greatly aggravates diseases of the
heart.
The drink should consist of water, soda-water, or seltzer-water.
All stimulants, as spirituous, vinous, and fermented liquors, should
be shunned ; the only exceptions being, when dyspeptic debility of
the stomach demands the addition of a glass of sherry or half an
ounce of brandy to a tumbler of water, or when an inveterate habit
of free living renders it dangerous suddenly and totally to abstract
stimulants : in which case, the patient may gradually be reduced to
the least requisite quantity. — which can often be brought so low as
one or two glasses of wine in the day. The total quantity of liquids
taken should be small, as a considerable quantity bloats the vessels.
This remark is peculiarly applicable to the plethoric. I have fre-
quently found their progress unsatisfactory till they were put upon
a dry diet.
Any exercise taken, should be so gentle as never to hurry, and,
if possible, not even to accelerate the circulation beyond a few beats.
Walking up hill is therefore out of question, even though the patient
declare that he can do it without inconvenience: riding on horse-
back is equally objectionable, and staircases should be avoided to
the utmost. The pace on level ground should not exceed 2k or 3
miles an hour for males, and the distance should not be such as to
produce lassitude. Gestation in a carriage is unobjectionable.
Purgatives should be used for a week or two with each of the
first bleedings, to co-operate with them in making a primary im-
pression. Also, when the action of the heart appears to increase,
and yet bleeding is not expedient, three or four copious and watery
alvine evacuations should be procured daily by saline aperients, of
which none answers better than one or two drams of sulphate of
magnesia in infusion of roses twice or thrice a day. This may be
continued for a week or ten days according to the effect ; and, in
plethoric patients, either the same, or some analogous aperient,
should be employed habitually in sufficient doses to keep the body
gently open, and to procure, if possible, softish evacuations. When
salines are used habitually, their debilitating effects on the intestinal
canal may be in a great measure counteracted by adding to the in-
fusion of roses an equal quantity of Comp. Infus. of orange-peel and
six or eight minims of dilute sulphuric acid. In-patients who are not
plethoric, the habitual use of aperients is unnecessary, beyond what
may be requisite to procure a single, natural evacuation daily.1
1 A respectable writer, overstraining the principle of draining away the
serous part of the blood, has proposed the habitual use of Elaterium as a
hydragogue. This, however, would not only be intolerable to the patient for
TREATMENT OF HYPERTROPHY. 283
In addition to purgatives, I have seen the most decided advan-
tage result, in severe cases, from diuretics, and not only when there
was dropsy, but also when there was none. Their mode of opera-
tion appears to be ultimately the same as that of purgatives : namely,
by draining off the serous portion of the blood. I have found many
patients, conscious of the benefit which they derived from this class
of remedies, in the constant habit of taking cream of tartar, broom-
tea, and other similar, popular medicines. One patient, affected
with contraction of the mitral valve to the size of an ordinary pea,
by these means warded off dropsy, beyond the slightest cedema of
the feet, for ten years.
When decided dropsy appears, it must be combated by the most
efficient diuretics — the supertartrate, acetate, hydriodate, and nitrate
of potass, squill, juniper, digitalis, spirit of nitric rcther, tincture of
cantharides, decoction of broom, &c, with mercury if not contra-
indicated. As no class of remedies is more variable and uncertain
than this, when one fails another should be resorted to ; and it not
unfrequently happens that a weaker is more successful than a
stronger. Should diuretics wholly fail, hydragogue purgatives, as
elaterium, tincture of jalap, infusion of senna with tartrate of potass,
&c. are often invaluable substitutes.
Acetate of lead, in full doses, possesses a powerful sedative action
on the vascular system; but, as it is a remedy which, if long admi-
nistered, is apt to derange the alimentary canal, its employment is
not desirable in so protracted a disease as hypertrophy. Fortu-
nately, it can be dispensed with.
Many patients have consulted me after having undergone a
course of hydriodate of potass, given with the view of creating ab-
sorption of the heart, as it does* of glandular structures ; but I never
could ascertain that the least benefit had been derived from its use.
The state of the stomach and of the biliary secretion should
never be overlooked in hypertrophy, as their derangements are
amongst the most efficient exciting causes of palpitation. The re-
medies suitable for dyspepsia and derangement of the liver are
therefore to be resorted to. I deem it unnecessary here to enlarge
on them, and on the treatment of dropsy, cough, dyspncea, (fee. as
these subjects will be found fully discussed in the chapter on Dis-
ease of the Valves.
It frequently happens that, notwithstanding the most judicious
use of the means specified, the irritability of the nervous system
frustrates their tendency to reduce and trauquillise the action of the
heart. In this case, sedatives are eminently useful, and I now re-
sort to them from the first in all cases where there is a considerable
disposition to palpitation. Their occasional use, however, is gene-
rally sufficient. I have often found excellent effects result from
tincture of digitalis to the extent of m. xx or xxx twice or thrice a
any considerable period, but would be apt to irritate the mucous membrane.
Finally, according to my observation, it is unnecessary — except in cases of
obstinate general dropsy, as will presently be explained.
284 HOPE ON DISEASES OP THE HEART.
day ; from a dram of tinct. of hops in mist, camph. administered as
often ; from three, four, or more grains of extr. of hyoscyamus or
corrium once or twice a day, from acetate or muriate of morphia,
and from these variously combined. The emplast. belladonnas is
also useful.
It must never be forgotten that the irritability of the nervous sys-
tem and the palpitation may be referable to anaemia, — indicated by
its usual signs, a pallid complexion, quick jerking pulse, debility,
<fcc. In this case, it is in vain to resort to sedatives, except as auxi-
liaries : the true remedies are, full doses of any of the stronger pre-
parations of iron, as the mist, ferri comp. or the ferri sesquioxyd,
&c. ; aloetic aperients to regulate the bowels ; and under-dressed
animal food at breakfast and dinner. When, by these means, the
due proportions of fibrine and red globules have been restored to
the blood, and the anaemic palpitation and irritability have been re-
duced, the treatment for the hypertrophy may be prosecuted on the
foregoing general principles, except that bleeding will rarely be
necessary, and the allowance of animal food may still be liberal. In
fact, the art of treating hypertrophy consists in keeping the patient
rather low, and the circulation very tranquil, yet short of producing
anaemia and debility. So far from debility being induced by the
measures recommended, I have generally found patients express
themselves as feeling lighter and more active. Under these circum-
stances of calmness without debility, the heart possesses a surprising
power of reverting to its natural size, — a power, which it was long
before I trusted myself to believe, and which is still disbelieved by
the bulk of those, who have not proved it by personal observation.
Yet it is not very incredible when we reflect on the rapidity with
which external muscles, (especially the hypertrophous muscles of
the legs in dancers, of the arms in smiths, &c.) become emaciated
and feeble, when exercise of them is wholly suspended.
The above, and indeed every other, mode of treatment is un-
availing, if not steadily pursued ; and it must be pursued for one,
two, or three years according to circumstances. The great majo-
rity of recoveries I have found to take place between one and two
years, but a year or two of subsequent precaution is most desira-
ble, to prevent a relapse. Two of the greatest impediments to
success are, first, that the patient, is often so much relieved at the
end of two or three months, as to believe himself well : secondly,
that other practitioners, finding the heart calm and the respiration
free, persuade him that he has not, and never has had, organic
disease of the organ. But " vje must be afraid of allowing our-
selves to be deceived by the perfect calm which blood-letting and
abstinence sometimes very 'promptly produce" (Laennec).
Though the treatment is prolonged, it is one which trenches
exceedingly little on the convenience and comfort of the patient, and
he is in general well contented to compromise, on terms so easy,
for emancipation from so formidable a disease.
As hospital patients do not remain long under observation, it is
TREATMENT OF HYPERTROPHY. 285
only from private practice that an estimate can be formed of the
success of the above treatment. The cases which I have collect-
ed from this source during the last ten years, afford me reason to
believe that nearly the whole who are under the age of 40, may
be radically cured, provided the hypertrophy is exempt from com-
plication with valvular or aortic disease, adhesion of the pericar-
dium, softening of the heart, or other organic obstacles to the circu-
lation ; and provided also, that the constitution is sound and the
general health tolerably good. The few exceptions that occur, are
principally those in whom the hypertrophy is very great, and has
advanced to the stage producing dropsy and much deterioration
of the general health. In persons under the age of 25, even this
degree not unfrequently admits of being cured. All degrees and
varieties yield more easily in the youthful ; and before the period of
puberty, it is not uncommon for a moderate degree to be cured,
although bleeding be resorted to only at Ion? intervals, as from six
weeks to three months. After the age of 40, the curability of the
disease is somewhat less, though it is not till the age of 50 or 55
that the difficulty becomes considerable. At this age, I have found
that, though hypertrophy can be diminished, and its urgent symp-
toms in a great measure removed, yet the patient continues under
the necessity of permanently maintaining a quiet, peaceable mode
of life ; as, otherwise, the disease returns.
The treatment described has the advantage of being suitable not
only for pure hypertrophy, but for the disease when complicated
with valvular or other impediments to the circulation. For the
hypertrophic part of the disease may be diminished, and sometimes
removed, — in which case the valvular or other impediment, (assum-
ing that neither dilatation nor softening supervene,) occasions com-
paratively little inconvenience. As, however, a valvular impedi-
ment is irremediable, the cure cannot be radical, and the patient
remains permanently under the necessity of adhering to a quiet
mode of life.
With respect to hypertrophy resulting from pericarditis and endo-
carditis, obviation should be the aim of the practitioner. If acute
rheumatism be treated on the principles already described, (p. 186,)
inflammation of the heart will not, according to my experience,
occur in more than one out of about twelve, instead of in every second
or third. If it should occur, a prolongation of the treatment for peri-
carditis and endocarditis, described at p. 190 and 220, will gener-
ally succeed in removing, or, rather, obviating the hypertrophy.
When this has actually taken place, and all inflammation has sub-
sided, I know no more suitable treatment than that for hyper-
trophy in general.
M. Bouillaud countenances the strict and rigorous application of
the treatment of Albertini and Valsalva " when the hypertrophy is
really enormous," and a slighter degree of it in moderate cases !
The possible occurrence of anaemic palpitation he wholly over-
looks ! — an inconsistency which is unaccountable ; since, in another
286 HOPE ON DISEASES OF THE HEART.
part of his work, he writes elaborately on chlorotic palpitation.
He is very partial to digitalis. " It is," says he, " incontestably the
most efficacious and direct of all sedatives — the true opium of
the heart." He has employed it with much advantage on the
endermic plan : that is, he applies a blister to the precordial region,
and daily covers the surface with the powder of digitalis, in doses
graduated from 6 to 15 grains. " We thus," says he, " diminish the
number and force of the heart's beat, as if by enchantment."
Patients, however, have a strong prejudice against digitalis, and
will not willingly submit to it long, or often, if its depressing effects
are rendered very sensible.
[The treatment marked out by Doctor Hope, of frequent small abstractions
of blood by the lancet, is vastly preferable to the heroic plan of Albertini
and Valsalva. By the former method the patient's strength is not materially
impaired, and his general health is preserved ; whereas, by the plan of prac-
tice of the celebrated Italian physicians, although his sufferings may be for a.
time alleviated, yet, if constantly pursued, especially in the advanced stages
of the disease, will produce great debility, increased paroxysms of palpitation
and dyspnoea, attenuation of the blood, and dropsical effusions.
Conjoined with moderate venesection and the exhibition of digitalis, local
depletion should not be lost sight of; and the application of cups to the in-
terscapular space, over the root of the lungs, is probably the preferable place.
When blood-letting is inexpedient, the exhibition of the mild diuretics is
advisable, and the combination of calomel, squills, and digitalis is one of
great value. Colchicum, also, is an useful auxiliary.
Iodine, from its well known property of promoting absorption, and from its
effects in controlling some of the results of chronic rheumatism, promises to
be a valuable remedy in this affection. It has been strongly advocated by
Dr. Colles and Mr. Salter.
The all important influence of the liver and digestive apparatus on the
heart should be constantly borne in mind, and care taken to avoid all causes
which might lead to indigestion or dyspepsia.
Where much irritability of the nervous system exists, it becomes impor-
tant to allay it; the extracts of hyosciamus, conium, or belladonna may be
judiciously employed ;x but great caution should be used in the employment
of opium and its preparations, inasmuch as it is apt to disorder the functions
of the stomach and brain, and in some individuals produce great derange-
ment of the system, " locking up the secretions, and so eventually aggravat-
ing the deranged action of the heart." Camphor and assafoetida, especially
the first, have an important influence during the paroxysms of palpitation
and dyspnoea. During these paroxysms, various palliatives may be employ-
ed— such as the several preparations of ether, warm pedituvia, immersion of
the hands and arms in warm water with mustard, the application of cups,
either dry or scarified, sinapisms, &c.
When the violence of the symptoms of the disease has been reduced,
counter-irritation should be employed, either by blisters over the precordial
region, or what is sometimes preferable, between the shoulders, which may
be dressed, should there be much pain, with the salts of morphia, or with
some of the other narcotics. The powdered digitalis may sometimes be
used, with great caution, on these denuded surfaces with advantage. Se-
tons, and issues in the arm, or in the chest at some distance from the heart,
are also useful adjuvants.
"In all cases, the patient, if he would avoid the speedy recurrence or ag-
1 The medicinal hydrocyanic acid, in doses of one or two drops, has been highly re-
commended — I have but little experience respecting its use. — P.
APPENDIX TO HYPERTROPHY. 287
gravation of the complaint, must make up his mind for a life of temperance
and self control, both moral and physical. All overloading the stomach,
whether with solids or fluids, however simple their nature, is to he studiously-
avoided, and a rather low scale of diet habitually adhered to. The age and
habit of body, and the previous mode of living, must, however, be taken into
consideration ; for an extreme system of abstinence will in many cases, by
deranging the digestive functions, and unduly augmenting the nervous sen-
sibility, give rise to a state of body veiy unfavourable to the regular and
moderate action of the heart. Though violent or prolonged exercises are
obviously improper, the opposite condition of total indolence and inactivity
is scarcely less to be shunned, except at very aggravated periods of the dis-
ease; the object to be kept in view being, on the one hand, to avoid all
undue excitement of ihe nervous, vascular, and muscular systems; and, on
the other, to support an equable distribution of power throughout the several
functions, a healthy action of the capillaries, and a free state of the secre-
tions and excretions, and so to guard against the dangers of plethora and of
local accumulation.'51 — P.]
APPENDIX TO HYPERTROPHY.
': Considerable doubt has been excited recently by the high
authority of M. Cruveilhier as to the real existence during life of
such a condition as hypertrophy with contraction. This anatomist
believes the diminished cavity to be merely the result of a tonic con-
traction of the muscular wall of the ventricle in death. ' The
concentrically hypertrophied hearts of Berlin and Bouillaud appear
to me,' he says, ' to be hearts more or less hypertrophied, which death
surprised in all their energy of contractility.'2 The hearts of all
those examined by Cruveilhier, who died by the executioner, pre-
sented to his observation to a great degree the double phenomenon
of increased thickness of walls and diminished cavity, and he has
observed the same with persons who died a violent death.3 On one
occasion I was particularly struck with a similar condition of the
heart of a donkey which had been accidentally transfixed by a large
trocar, whereby the death of the animal was caused in a few min-
utes. The muscular structure of the heart was singularly dense.
It hadcontracted at its apex quite to a sharp point, and on cutting
into it, the cavity of the left ventricle appeared almost obliterated,
and the muscular wall much increased in thickness. I have many
times, too, observed the fact noticed by Cruveilhier, that the cavity
may be easily enlarged or restored to its natural dimensions by
introducing the finger and dilating it, or still more easily, if the
heart have been macerated in water for a short time previously.
This fact is further confirmed by Dr. Budd, who supports the
views of Cruveilhier in an interesting paper in the last volume of
the Medico-Chirurgical Transactions. In one of Dr. Budd's cases
the thickness of the parietes of the left ventricle eighteen hours after
1 Dr. Joy, Tweedie's Library.
2 Diet, de Med. et Chir. Prat., art. Hypertrophic
8 Mr. Jackson and Dr. Budd have observed this stale of the heart in per-
sons who died of cholera,
288 HOPE ON DISEASES OF THE HEART.
death varied from an inch to an inch and a half, on a transverse
section made at a distance from the apex of one-third of its length,
and the cavity was not large enough to hold the second phalanx of
the t'humb, and was almost filled by the carneae columna3. This
heart, in its open state, was put to macerate ; no force ivas applied
to extend it. At the end of some days, on being folded up, it was
found to have dilated very considerably, so that the left ventricle
could not then be said to be smaller than natural. Dr. Budd argues
against the existence of the diminished cavity from the fact that
of eight cases collected by him, no one afforded signs, either during
life or after death, of any obstacle to the circulation through the
heart. There were no irregularity of pulse, no dropsy during life,
no dilatation of the right cavities after death, phenomena which, it
may be said, must of necessity be present if there be an obstacle to
the circulation in the heart. It is impossible, as he states, to con-
ceive that a left ventricle, which could scarcely hold an almond,
should offer no obstacle to the circulation through the heart. Yet
Laennec has recorded a case in which the parietes of the left ven-
tricle had acquired the thickness of from an inch to an inch and a
half, and the cavity seemed capable at most of containing an almond
stripped of its shell. Yet the day before the patient's death his
pulse was natural, the breathing perfectly free, 'nothing, says
Laennec, 'led me to suppose that this man had a disease of his
heart.'" (See Cycloped. of Anat. and Physic. Abnormal Conditions
of the Heart, by Dr. R. B. Todd, p. 12.)
CHAPTER II.
DILATATION OF THE HEART.
SECTION I. — Anatomical Characters, with classification and nomenclature of
Dilatation.
The disease commonly termed dilatation of the heart, consists in
an amplification of one or more of its cavities.
Although I have seen the muscular substance healthy in every
form and degree of this affection, in general it is not so. For, when
the dilatation is great, and the parietes are feeble in proportion to
the quantity of blood which they have to propel, the muscle is
usually more or less flaccid, and even softened, and in some cases
of a deeper red, in others paler or more fawn-coloured than natural
(Gillan, Anderson, Mrs. — 1 — n). The deep red dye is attributable
to venous engorgement of the muscular substance, resulting from
stagnation of the blood within the heart. The paleness is often
connected with general muscular paleness, The softening is some-
times so great that the substance readily breaks up under the pres-
sure of the fingers.
Dilatation occurs with three different states of the ventricular
DILATATION OF THE HEART. 289
parietes as to thickness : namely, the thickened, the natural, and the
attenuated states. It accordingly resolves itself into three natural
varieties corresponding with these states.
1. Dilatation with hypertrophy, in which the cavity is enlarged
and the walls thickened.
2. Simple dilatation, in which the cavity is enlarged, and the
walls of their natural thickness.
3. Dilatation with attenuation, in which the cavity is enlarged
and the walls attenuated.
The first variety is identical in its nature with that variety of
hypertrophy called hypertrophy with dilatation : the only diffe-
rence consists in the relative degrees of the two affections, and this
difference is indicated by giving precedence to the term hyper-
trophy in the one, and dilatation in the other. Thus, hypertrophy
with dilatation denotes a predominance of hypertrophy ; whereas
dilatation with hypertrophy bespeaks a predominance of dilatation.
The second variety is perfectly identical with hypertrophy by
increased extent, with natural thickness of the w alls ; but it is
better to employ the term simple dilatation when the dilatation is so
great, or the patient so enfeebled, that its symptoms predominate
over those of hypertrophy.
Two, or all three of the forms of dilatation are sometimes found
together, in different parts of the same cavity. Tt is sufficient to
notice the fact, without perplexing the memory with a distinct
appellation for cases of this compound nature.
The anatomical characters of dilatation with hypertrophy, and
simple dilatation, are described in the chapter on Hypertrophy, p.
240. To dilatation with attenuation we now direct our attention.
It seldom affects one ventricle without the other. The attenuation
may proceed to such an extent as to reduce the most substantial
part of the left ventricle to two lines in thickness, and the apex to a
mere membrane. In a case lately under my observation,, the pre-
vailing thickness was two lines, (Lambert,) and a portion of the
apex consisted solely of the internal and external membranes,
strengthened by a deposition of lymph on the outside. Extreme
attenuation is more common in the right, than in the left ventricle.
In either, the columnar carneas appear stretched and spread. The
inter-ventricular septum is, proportionably, much less attenuated
and softened than the other parts. Dilatation takes place more in
the transverse, than in the longitudinal direction of the ventricles,
and it accordingly communicates to the heart an unusually spherical
form, so that the transverse diameter of the organ is often as great or
greater man the longitudinal, and the apex is rounded off in such a
manner as frequently to be scarcely distinguishable. This altera-
tion .of shape is the best criterion for determining whether a heart
is dilated or not, when the enlargement is so inconsiderable as to
render the question doubtful.
When both the auricle and ventricle are much dilated, it is not
unusual to find the intermediate aperture widened, and its valve
10— g 19 hope
290
HOPE ON DISEASES OF THE HEART.
sometimes not large enough to close it. As this causes regurgita-
tion, it is as serious a malady as disease of the valve itself, produc-
ing the same effect. It should be understood by the practitioner,
because it is apt to be overlooked, post mortem, in cases which had
presented signs of regurgitation ; and, thus, his confidence in val-
vular diagnosis is apt to be shaken.
[As it is of great importance to the pathologist that he should have accurate
ideas of the natural size of the cardiac orifices, the following measurements
are presented. The first series, those of M. Bouillaud, are the measures of
their circumference in the natural and dilated states.
MITRAL.
Natural.
Medium 3 in. 8-A- 1.
Maximum 4 in.
Minimum 3 in. 4t4q 1.
AORTIC.
Dilated.
4 in. 4TV 1.
Dilated.
Natural.
Medium 2 in. 7T\1.
Maximum 2 in. 10TV 1. 3 in. 7T\].
Minimum 2 in. 5T\ 1.
TRICUSPID.
Natural.
4 in. -A- 1
4 in
_9_
10 ,
3 1.
3 in. 11-&-1-
Dilated.
5 in. 6vW ]
6
4 in.
6TV
n. 3TV 1.
K 3
PULMONIC.
Natural.
2 in. 9
3 in.
2 in.
ftl.
8 I.
Dilated.
3 in. 5TV 1.
The above measurements are derived from the examination of but a few
hearts, not more than six or seven ; too small a number to justify implicit
confidence as to their entire correctness as indicating the medium of the
measure of all hearts.
M. Bizot's results, however, are founded upon the measures of one hundred
and fifty-seven hearts, and are entitled to the highest respect. His tables,
exhibiting the dimensions of the different valvular orifices, are subjoined; it
must be constantly recollected that his measures are those of the French
foot, which is equal to 12.7893 inches English measure. The aortic and
pulmonary orifices were measured by opening the vessels and taking their
circumference on a level with the free edges of the sigmoid valves; that of
the auriculo-ventricular openings, by measuring the line of adhesions of the
tricuspid and mitral valves.
ORIFICES OF THE HEART.
Orifices of the Heart according to Age and Sea:. — Circumference of the
Auriculo-ventricular Valves.
Left.
MALES. FEMALES.
Lines.
26
27-9-
31f
38
401-f
411 lines.
45ii lines French = 48^-g- lines English = 4 in. if- lines.
41i lines French = 44^ lines English = 3 in. 8^ lines.
Ages.
1 to 4
5 to 9
10 to 15
16 to 29
30 to 49
50 to 79
Med. 16 to 79
Lines.
251
30
Fl
Ages.
34f
41
4811
50 to 89
4511 lines.
16 to 89
DILATATION OF THE HEART.
291
Bight.
MALES.
FEMALES.
Ages.
1 to 4
Lines.
29f
Ages.
Lines.
27
5 to 9
34
32 rV
30 to 15
39
34
16 to 29
50T9¥
37}§
30 to 49
50 to 79
54/3
5?S
50 to 89
47_4_
2 7
49111
Med. 16 to 79
54|f lines.
16 to 89
48'- lines
54£f lines French :
48i lines French =
= 57i£ English = 4 in. 91J- lines.
= 51±| English = 4 in. 3*§ lines.
CIRCUMFERENCE OF THE AORTIC ORIFICE,
Taken on a Level with the Free Edge of the Sigmoid Valve.
MALES. FEMALES.
Ages.
Lines.
1 to 4
17
5 to 9
181
10 to 15
211
16 to 29
26H
30 to 49
30|^
50 to 79
36
from 16 to 79
31^5
ox6 1
Ages.
50 to 89
Lines.
16T'r
171
19
24J
38f
Gen. med.
1. Gen. med. from 16 to C9 284 1.
31$f lines French = 33TV English = 2 in. 9TV lines.
28| lines French = 30J- English — 2 in. 61 lines.
CIRCUMFERENCE OF THE ORIFICE OF THE PULMONARY ARTERY,
Taken at the corresponding point
Ages.
Lines.
Ages.
1 to 4
18f
5 to 9
19*
10 to 15
22i
16 to 29
29T\
30 to 49
3Hf
50 to 79
35
50 to 89
Med. 16 to 79
32f| 1.
16 to 89
Lines.
17
m
20f
29^
mi
30^V I-
32|i lines French = 34^ English = 2 in. 10-^ lines.
30^ lines French = 3 1 f | English = 2 in. 7|f lines.— P.]
Laennec, although he had never seen a case of rupture of the
heart from dilatation, believes, with Burns, that it may occur ; par-
ticularly, as dilatation is generally attended with softening-. I wit-
19*
292 HOPE ON DISEASES OF THE HEART.
nessed a case of this kind a few years ago. The patient, who was
aged upwards of seventy, fell back suddenly while on the night
chair, and immediately expired. A fissure an inch in length was
found in the left ventricle, its substance was softened and of a deep
violet colour, and the cavity of the pericardium was gorged with
blood. Dr. Williams communicated to me the case of a relation of
his, who died from rupture of the heart in a somewhat similar way ;
but the orifice through which the blood escaped was small, round,
and encircled by dark ecchymosis. The patient (a lady of fifty-
eight) had been subject to severe angina for some months before her
death. He suspects that there were both attenuation and softening
in this instance, but is not sure, as he did not see the body.
In order to judge accurately of dilatation of the auricles, it is
necessary to have distinct ideas respecting their natural form and
dimensions. The four cavities of the heart are very nearly equal
in capacity ; but, as the parietes of the auricles are very thin, and
those of the ventricles are thick, the auricles, when simply full and
not distended, form only about one third of the total volume of the
organ ; or. what is the same thing, the volume of the auricles equals
about half that of the ventricles (Laennec de l'Auscult. torn. ii. p.
523). The right auricle, being generally found in a state of disten-
tion, and being of a more elongated, flattened form than the left, has
the appearance of being considerably larger, though in reality it is
only a little so.
Distention, taking place during the last moments of life, and ob-
servable, though more rarely, in the left auricle as well as in the
right, constitutes the great source of fallacy in determining after
death whether these cavities are really dilated or not ; for the en-
gorgement, though only of a few hours' duration, may stretch them
to a magnitude almost equalling that of the ventricles.
M. Laennec has given good criteria, by which a dilated may be
distinguished from a distended auricle. An auricle simply dis-
tended is tense, and through its thinnest parts distinctly shows the
dark blood within. One dilated, does not present the same appear-
ance of tension, and its parietes are more opake. When the blood
is evacuated through the vessels without cutting into the cavities,
the latter, if merely distended, return at once to nearly their natural
size : whereas, if dilated, they maintain almost the same size which
they had when full. Dilatation of the auricles, as already stated,
scarcely ever exists without more or less thickening of their
parietes.
The method of distinguishing distention from dilatation is much
the same in the ventricles as in the auricles: namely, when merely
distended, they are found enlarged, firm and tense ; but these con-
ditions almost entirely disappear, when the blood is pressed out
through the natural apertures. On the contrary, when truly dilated,
they have no appearance of tension, are more or less flaccid, and
the enlargement persists after the blood has been evacuated.
FORMATION AND CAUSES OF DILATATION. 293
SECTION II. — Mode of Formation, with the predisposing and exciting Causes of
Dilatation.
Dilatation of the heart is a purely mechanical effect of over-dis-
tention. Blood, accumulated within its cavities, exerts a pressure
from the centre towards the circumference, in every direction ; and
when once it surmounts the resistance offered by the contractile and
elastic power of the parietes, these necessarily yield and undergo
dilatation. The rapidity with which this process takes place, and
the extent to which it is carried, depend on the degree in which the
distending exceeds the resisting force : and a;, the latter bears a
direct ratio to the volume of the muscle, supposing it to be healthy,
it follows that individuals with naturally thin-walled hearts are
more prone to dilatation than others : supposing the muscle not to
be healthy, — supposing it to be flabby or softened, (from general
emaciation, anaemia, typhus, scurvy, purpura, inflammation of the
heart, or any other cause of softening specified in the chapter on
that subject,) its resisting power is diminished by these circumstan-
ces, and it is more susceptible of dilatation by the distending power.
In any case, those cavities of the heart which have the thinnest
parietes, are, casteris paribus, the most susceptible of the disease.
Accordingly we find that the right ventricle is more frequently and
promptly dilated than the left, and the auricles than either, when
exposed to distending causes.
In order to produce permanent dilatation, the operation of the
exciting cause must either be prolonged for a certain time, or fre-
quently repeated at brief intervals. Contraction of an orifice, for
instance, acts in the former manner ; and nervous palpitations, and
occupations requiring constantly renewed and long sustained mus-
cular efforts, produce their effect in the latter way. When the ope-
ration of the cause is only brief and transitory, the result is merely
a temporary distention, from which the muscle recovers itself by
its own elastic and contractile reaction so soon as the distending
force is removed. This cannot be regarded as a pathological state,
and it must, therefore, be carefully distinguished from genuine dila-
tation.
The causes of dilatation, are, 1st, deficient power of the heart,
whether congenital or acquired, in proportion to the system : 2d, in
general terms, all obstructions to the circulation, whether situated
in the orifices of the heart, or in the aortic, or pulmonary system.
The second class of causes is, in fact, essentially the same as the
exciting causes of hypertrophy, independent of inflammation (see
p. 246). For, as stated under hypertrophy, it depends on the pro-
portion which the resistance of the muscle bears to the distending
force, whether the one affection or the other be produced. When,
therefore, dilatation occurs in one of the cavities with naturally
thick walls, in which we should more properly expect hypertrophy,
it must be ascribed, either to a congenital disproportion of the heart.
294 HOPE ON DISEASES OF THE HEART.
in consequence of which the cavity in question is thinner, and
therefore more disposed to dilatation, than natural ; or it must be
attributed to the obstruction, from its nature or situation, bearing
more m proportion on that particular cavity, than on any other.. It
is from overlooking these considerations, respecting the relations of
the resisting and distending forces to each other, that some have
excluded dilatation from the catalogue of mechanical diseases, and
supposed that it takes its rise in any cavity of the heart either by
chance, or by some vital predilection, some vague, unintelligible
predisposition.
Dilatation occasionally affects only a single ventricle, and it is
generally the right, and seldom in a great degree : much more com-
monly it attacks both, and then the degree may be greater in either.
The auricles, being protected by their valves from the direct influ-
ence of the numerous causes of pressure which operate on the ven-
tricles, are far more exempt both from dilatation and hypertrophy.
But when the auricular valves are diseased, whether their state be
that of contraction, which impedes the transmission of the auricular
blood, or of permanent patescence, which allows a regurgitation of
the ventricular, the auricles, suffering unnatural distention, become
dilated.
It is seldom that dilatation of the auricles occurs under any other
circumstances than those of diseases of their valves: so seldom, in-
deed, that Laennec does not recollect to have seen an instance,
though he does not deny the possibility of the occurrence. More
instances than one, however, have fallen under my own observa-
tion, and 1 have generally found the dilatation connected with some
circumstances which rendered the ventricle incapable of freely
evacuating its contents. It is natural, indeed, to suppose, that,
when such is the case, the stagnation of blood in the ventricle must,
for the time, have an effect in distending the auricle equivalent to
that produced by contraction of the auriculo-ventricular valve ; and
considering the frequency of stagnation in the right ventricle, we
might at first expect dilatation of the corresponding auricle from
this cause, to be frequent. But it must be remembered that, for
the production of the disease, it is necessary that the operation of
the cause be permanent, or at least very prolonged. Such, how-
ever, is seldom the case with the stagnation in question ; for a
ventricle, though so feeble in itself, or so encumbered by an ob-
stacle before it in the course of the circulation, as to become gorged
during an accelerated state of the heart's action, will often, when
tranquillity is restored, transmit its contents with a facility that
could scarcely be anticipated. During such intervals, therefore,
the muscular fibres of the auricle recover their contractile power,
and restore the cavity to its natural size. Hence it is, that, though
dilatation of the auricles is occasionally a result -of ventricular en-
gorgement, it is much more commonly dependent on imperfections
of the auricular valves.
PATHOLOGICAL EFFECTS OF DILATATION. 295
[" The anatomical characters of dilatation are not only the thinning and ex-
tension of the walls of the affected compartment, but also generally a paler
and more flaccid condition of their muscular fibres. In some parts, particu-
larly of the auricles, and at the apex of the left ventricle, the attenuation of
the walls has sometimes proceeded so far, that the pericardium and endo-
caidium are in contact, and these are occasionally thickened by opake de-
posit, as if to strengthen them at these parts.
The right ventricle and the left auricle are the most common subjects of
simple dilatation. In the other compartments it is occasionally met with,
but more generally combined with some degree of hypertrophy ; so that, al-
though the walls be thinner than natural, the greater extent gives them an
increase of substance. The right auricle and ventricle are sometimes dilated
to an enormous extent, with thinning of their walls, but still with increase of
substance ; and this condition is generally found to be associated with dis-
ease of the mitral valve. Dilatation of the ventricles is commonly in all di-
rections, rendering the cavities globular; but it is occasionally partial, the
walls being distended into a pouch or aneurism, which in rare instances at-
tains a considerable size and may end in rupture. With the dilated condi-
tion of the walls there may appear various other traces of disease in the
lining membrane and valves; such as opacity, thickening, and roughness.
The orifices and their valves are commonly somewhat dilated, as well as the
other walls, so that they may still maintain a sufficient proportion to perform
their office. The dilatation of the semilunar valves is sometimes consider-
able, and renders them so thin that the fibrous threads can be seen forming
an irregular net-work in them. Their thinning sometimes amounts to per-
foration, especially at the margins which apply to each other, and then this
fibrous net-work may be the only part left. The tricuspid valve is seldom
expanded iu proportion to its orifice, which almost always partakes of the
dilatation of its ventricle; hence there is free regurgitation through this
orifice." — C. J. B. Williams' 's Lectures, $c— P.]
SECTION III. — Pathological effects of Dilatation, and mode of their production.
"Authors," say MM. Bertin and Bouillaud, " have entered into
long disquisitions on what are called the general symptoms of dila-
tation or aneurism of the heart, and they have allowed themselves
to fall into great errors in considering dilatation a primitive mala-
dy, instead of regarding it as consecutive to another lesion, which
was the source of the symptoms that they attributed to the dilata-
tion itself. We have already proved, continue they, that this mala-
dy necessarily supposes an obstacle to the course of the blood ; but
this obstacle, at the same time that it gives rise to an aneurism of
the heart, produces other striking phenomena, such as engorgement
of the vessels, serous infiltration, passive hemorrhages, &c. These
phenomena have been taken for the effects of the dilatation of the
heart, while this has, strictly speaking, no other relation with them
than as being a result of the same cause, that is to say, of an em-
barrassed state of the circulation" (p. 3S2).
I cannot concur with MM. Bertin and Bouillaud in these
opinions. It is true that, in order to produce dilatation, there must
exist a weight or pressure of the circulation upon the heart greater
than the organ is capable of sustaining : and it is true that such
pressure may be occasioned by the mechanical obstacles to which
296 HOPE ON DISEASES OF THE HEART.
MM. Bertin and Bouillaud ascribe it : namely, contraction of the
orifices of the heart, diseases of the aorta, and all maladies which
impede the course of the blood, whether in the lungs, or in the sys-
tem of the great circulation (p. 380). But it is equally true that
the same pressure on the heart may result, not from increased
weight of the circulation, but from deficient power of the heart; and
such is its cause in those, who, by original conformation, have the
organ thin, in proportion to the size of the body. I believe that this
is a more powerful and certain cause of dilatation than the impe-
diments alluded to by Bertin and Bouillaud ; for the malady pre-
vails principally in the female sex. in whom the walls of the heart
are, in general, thinner than in men : though women are less ex-
posed than men to the exciting causes of dilatation, as they lead a
more tranquil, temperate life, and are less subject to diseases ofthe
arteries and valves. Another class in whom debility of the heart
exists as a cause of dilatation, comprises those who have had the
organ softened or otherwise enfeebled by disease : an effect not un-
frequently produced by typhoid fever, by inflammation of the sub-
stance ofthe heart, and by other causes specified in the chapter on
Softening.
Dilatation, then, occurring under the circumstances described, is
as justly entitled to the rank of a primitive disease, as hypertrophy :
for as, in both, the disease depends, not on the pressure ofthe cir-
culation, but on the manner in which the heart resists that pressure;
in both, the organ itself is the part where the disease originates :
the only difference being, that the effect is produced in the one case
by deficient, and in the other, by superabundant power ofthe muscle.
In the next place, MM. Bertin and Bouillaud have, in my opinion,
attributed far too much to the mechanical obstacle of which they
consider dilatation to be the effect, when they say that this obstacle is
the sole cause of all the symptoms, which authors have been in the
habit of ascribing to dilatation; namely, passive congestions and
hemorrhages, dropsy, &c. It is true that when the obstacle is so
great as to constitute an extreme impediment to the circulation, it
may produce the symptoms in question ; but it does not produce
them, or only in a very slight degree, when the impediment is not
extreme. I have repeatedly witnessed cases in which a well marked, if
not a considerable obstacle, as a contracted valve, a regurgitation, or
a dilatation or aneurism of the aorta, had subsisted for a long period,
even for years, without producing any material symptoms of an
obstructed circulation ; but the moment that dilatation of the heart
supervened, the symptoms made their appearance in an aggravated
form. I apprehend, therefore, that the heart is the part mainly con-
cerned in their production : nor do I think this opinion less tenable
because the symptoms are more severe when dilatation ofthe heart
co-exists with an obstacle, than when the dilatation exists alone;
for it is natural to suppose that, when two causes conspire to produce
the same effect, that effect should be greater. But this is not all;
for not only does each produce its own effect, but one increases the
PATHOLOGICAL EFFECTS OF DILATATION. 297
effect of the other : namely, the obstacle adds so much to the pres-
sure of the circulation on the heart, that this organ labours under a
double disadvantage, first, from its own diminished power, and
secondly, from a preternatural pressure upon it. Thus the resulting
effect of the obstacle and the dilatation of the heart combined, is
greater than the sum of the two taken separately.
In further invalidation of MM. Benin and Bouillaud's opinion,
I may add that I have not .only seen numerous cases of a mechani-
cal obstacle unattended with passive congestions, dropsy, <fcc. ; but
I have seen a still greater number of instances in which all the
phenomena of an obstructed circulation were occasioned by dilata-
tion alone ; as no other obstacle capable of accounting for them,
could be detected in the course of the circulation. Such cases, in
fact, are of ordinary occurrence, and. when flabbiness or softening
co-exists with dilatation, the effect is still more marked.
According to the foregoing arguments, then, it appears, 1. that
dilatation may be a primitive disease ; and that, as such, it is ca-
pable of producing all the phenomena of an obstructed circulation.
2. That when it is consecutive to another lesion, it plays a promi-
nent, and perhaps even, in some cases, a more important part than
that lesion, in producing the phenomena of an obstructed circula-
tion.1
1 M. Bouillaud, in his Treatise in 1S35, avows himself to be the author of
the opinions which I controvert. In reference to them, and similar ones
applying to hypertrophy, I stated in the1 Introduction to this work, (p. 19.)
that AIM. Benin and Bouillaud considered " the symptoms of a retarded
circulation to be, under all circumstances, the result of a mechanical ob-
stacle to the course of the blood." M. Bouillaud complains, in his Treatise
in 1S35, (vol. i. p. 267, note.) that I have, in these words, mis-stated his
opinions, and lie cites, in proof, the following passage from his conjoint
work with Bertin, in 1S24. " It is very clear that, considered in an abstract
manner, (these words in italics M. Bouillaud omits in his citation) dilatation
of the heart has the effect of enfeebling the contractile power of the muscular
substance of this organ, by reason of the distention which it causes the organ
to undergo. The muscular fibres lose, as it were, in force, what they gain
in length. Thus, then, if we conceive of this dilatation, abstracting {en
faisant abstraction) the cause which has occasioned it, we should give
(donnerions) to it, as signs, feebleness and softness of the pulse, dropsies
and passive hemorrhages, in a word, all the phenomena which we know to
be the result of an obstacle to the circulation" (Traite de Bertin et Bouil-
laud, p. 3S4). " I am, then," says M. Bouillaud, in his remarks appended
to this citation, "agreed with Dr. Hope on this point — that dilatation can, of
itself, produce the symptoms of obstruction or embarrassment of the circu-
lation."
I rejoice to find that M. Bouillaud makes this admission, because I sin-
cerely believe that he has done an injury to practice by maintaining the op-
posite opinion. But, as he has charged me with misrepresenting his opinions,
I am now under the necessity of showing that he has arrived at his ad-
mission at the expense of contradicting himself in every other part of his
works, both in 1S24 and 1S35. In doing this, I shall simultaneously show
that I have given a fair statement of his opinions.
He has not accurately quoted the above passage from the work in 1S24.
He has suppressed the clause in italics at the commencement of the passage,
298 HOPE ON DISEASES OF THE HEART.
As, in cases of dilatation combined with a mechanical obstacle,
it is impossible " to assign to the dilatation and the obstacle, the
exact proportion which each bears in the production of the same
has stopped at a semicolon, instead of concluding the sentence, and has not
alluded to the previous sentences. The introduction of these omissions re-
verse the meaning of the whole passage. The reader shall judge for him-
self. In the previous sentence he says, " I have shown above that dilatation
of the heart was the mechanical result of a cause which occasioned engorge-
ment of the cavities of the organ, and that it was to the action of this cause,
instead of to the dilatation itself, that we were to refer divers symptoms
which authors have attributed to the latter. The dilatation being produced,
we must now examine what may be its influence on the system of the circu-
lation. Now, it is very clear that, (here comes the suppressed clause,) con-
sidered in the abstract, dilatation has the effect of enfeebling, &c." The
sentence then concludes thus: — ".; but as the cause of the dilatation is
itself capable of producing all these phenomena, it is very difficult to assign,
to the dilatation and to its cause, the exact part which it takes in the pro-
duction of the same effects." The import of the passage, now, stands thus :
— Dilatation has always a mechanical cause : if, by a stretch of imagination,
we could conceive of the dilatation as abstracted from its cause, we should
assign to it certain phenomena ; but, as this abstraction is wholly a flight of
imagination, we must assign the phenomena to the cause of the dilatation
itself, admitting, however, that the dilatation, when once produced, may co-
operate in the generation of the effects. The same ideas are expressed, in
the most unqualified terms, in another passage from the same Treatise, (viz.
of 1S24,) quoted above at p. 295 ; and again, in a third passage, at p. 227 of
the Treatise: namely, "many authors have stated these signs, (viz. of an
obstructed circulation,) as being peculiar to aneurism of the heart: it is a
great error ; for, far from the aneurism of the heart being the first mover
of the phenomena which we observe, it is itself only one of the effects, and,
so to speak, one of the accidents, of contraction of the orifices"!
Similar statements run throughout M. Bouillaud's work in 1835. For
instance, in vol. ii. p. 216, note, he repeats the passage just quoted. The
same, in rather different words, is reiterated at p. 613. The same, in re-
ference to active aneurism, (hypertrophy,) is repeated, in unqualified terms,
at p. 445. Viz. " Passive congestions, whether of blood or serum, do not in
reality occur, except in cases where hypertrophy is complicated with other
lesions capable of opposing an obstacle to the course of the venous blood, —
as contractions of the orifices or cavities of the heart, and important organic
lesions of the principal arteries or veins." He reiterates the same, in equally
unqualified terms, at p. 447, and represents himself to have exposed a general
error of authors! The only resemblance to a qualification that I can find in
the whole work, is in the chapter on Dilatation, p. 532, where, (as if he had
recently been reading my remarks in the text above,) instead of saying, in
all cases, he only says, " in the immense majority of cases, the above acci-
dents (i. e. passive congestions, dropsy, (%-c.) are referable to a mechanical
obstacle to the course of the blood, which is at the same time the cause of
the dilatation." Yet even this qualification he annihilates in the next
sentence: for he adds, " not that dilatation does not sometim.es play a certain
part (never, therefore, the whole) in the production of the accidents;
but, once more, its influence has been exaggerated; and, in a number of
cases, hypertrophy does more than compensate for the weakness which
might result from dilatation." If any doubt remain -as to M. Bouillaud's
opinion, the following passage is a coup de grace. "We see here again
that M. Louis uses the word aneurism in the vague acceptation which it
has received from certain authors. No, a hundred times, no! Most of the
symptoms to which M. Louis here alludes, are not, correctly speaking, those
PATHOLOGICAL EFFECTS OF DILATATION. 299
effects," it is necessary, in order to ascertain the real effects of dila-
tation, to confine ourselves, in studying them, to the simple, un-
complicated form of the disease.
Taking into consideration this form alone, and admitting, on
the foregoing grounds, that it is capable of producing nil the phe-
nomena of an obstructed circulation, we have next to inquire how
or by what mechanism it produces them. To answer this ques-
tion,— it produces them by putting the muscular fibres of the heart
preternaturally on the stretch, whereby their contractile power is
diminished : " they lose, as it were, in force what they gain in
length ;'; and it is this deficiency of power in the main spring of
the circulation which constitutes the obstacle, if it may be so called,
to the circulation; in the same way that weakness of the spring of
a time-piece retards its movements.
It must be distinctly understood that these observations do not
apply to dilatation with which a predominant degree of hypertrophy
is conjoined, for the heart then acquires more force in virtue of
the hypertrophy, than it loses by the dilatation, and the conse-
quence is, an increased, instead of a diminished energy of the cir-
culation. Less hypertrophy than is generally supposed, suffices to
occasion this increased energy. It is not even essential that the
walls of the heart be thickened at all, provided the muscular fibre
is healthy, the constitutional powers unimpaired, and the dilatation
moderate, that is, not so excessive as to be greatly out of propor-
tion to the thickness of the walls. It is in consequence of such
cases being attended with increased energy of the circulation, that
it has been necessary to transfer them from the class of dilatation
to that of hypertrophy, where they constitute the variety Called
hypertrophy by increased extent, without thickening, of the walls.
MM. Benin and Bouillaud conceive a case in which, the heart
gaining, in virtue of its hypertrophy, precisely as much as it loses
by reason of its dilatation, there results a sort of compensation or
equilibrium, which maintains the functions in their healthy condi-
tion (p. 385). It would be erroneous, however, to suppose that this
of aneurisms or dilatations of the heart, but, in fact, those of a lesion of the
Valves with obstacle to the circulation. If I expose this error again and
again, it is because it still reigns generally in the minds of observers other-
wise the most distinguished, and because one cannot make truth triumph
except by defending it with perseverance" (Traite, ii. p. 573, note) !
Notwithstanding all the above, M. Bouillaud comes, with unaccountable
inconsistency, to the conclusion, " I am agreed, then, on this point with
Dr. Hope .... namely, that dilatation can, of itself produce the symptoms
of obstruction or embarrassment of the circulation" (vol. ii. p. 268, note)!
If, however, M. Bouillaud does me the honour of agreeing with me, he
must correct all the passages which I have quoted. "Till then, with the
utmost anxiety to be just, I cannot comprehend that I have mis-stated his
opinions; and I should not have dwelt on this subject, had it not been from
anxiety to check a most important error, which might easily become current
under the shade of so justly authoritative a name as that of M. Bouillaud.
That portion of the error which applies to hypertrophy, has already been
refuted at p. 254.
300 HOPE ON DISEASES OF THE HEART.
is not a state of positive disease ; for, though the functions may be
adequately performed while the circulation is tranquil, whenever
it is hurried, the heart, either, unable to contend with the increased
pressure of the blood, becomes gorged ; or, struggling against, and
surmounting the obstacle, it palpitates violently, contracts beyond
its normal degree, and expels an excess of its contents with preter-
natural force. In either case, the lungs become congested, — in the
former, from retardation of the blood in the pulmonary veins, — in
the latter, from an excessive influx through the pulmonary artery ;
and in either case an attack of dyspnoea is the consequence.
SECTION IV.— Signs and Diagnosis of Dilatation.
In the preceding section I have shown that the effect of dilatation
is, to enfeeble the heart, and thereby occasion the phenomena of an
obstructed circulation. We have now to examine those phenomena
as signs of dilatation.
General Signs. — The heart, when weakened by dilatation, is
subject to palpitations of a feeble, oppressed kind, and more or less
distressing, frequent, and prolonged, according to the extent of the
malady. In general, they are protracted. The attacks are pro-
voked by any over-exertion or mental excitement.
The pulse is soft and feeble, and, if the debility of the heart be
very considerable, it is small. Irregularity and intermittence are
rare, except during protracted and distressing paroxysms of dys-
pncea, or when the vital powers are much exhausted, as in the ad-
vanced stage of the disease. When, however, softening accom-
panies the dilatation, I have found that the pulse is apt to be as
small, weak, intermittent, irregular and unequal, as in the worst
cases of disease of the mitral valve; with which, for this reason,
softening is frequently confounded. (See Softening, for the Dia-
gnosis.)
The languor of the arterial circulation in dilatation causes the
extremities and surface to be chilly, the disposition to be melan-
choly, and the character to be deficient in energy.
The blood, not being freely transmitted by the left ventricle, ac-
cumulates in the lungs by retardation: whence difficulty of res-
piration ; cough, sooner or later attended, in many cases, with
copious expectoration of thin, serous mucus; oedema of the cel-
lular tissue of the lungs, greatly aggravating the dyspnoea ; terrific
dreams with starting from sleep ; and passive, pulmonary hemor-
rhage of dark, grumous blood in small quantities, forming sanious
sputa, and generally the precursor of death in individuals affected
with great difficulty of respiration. After death, I have often found
this hemorrhage connected with pulmonary apoplexy, and always
with great engorgement.
The lungs being obstructed, the engorgement is propagated back-
wards to the right side of the heart, to the great veins, and finally
SIGNS AND DIAGNOSIS OF DILATATION. 301
to all their ramifications. From this venous engorgement arises
a series of striking phenomena, which we shall review successively,
premising that the hemorrhages and dropsy do not generally come
on till a late stage of the disease.
1. Serous infiltration. This generally makes its appearance
first in the lower extremities, because it is in them that the circu-
lation is most languid, the return of the blood being opposed by its
gravity, while it is little promoted by the action of superincumbent
muscles. The oedema gradually ascends, and, under the name of
anasarca, may eventually attain the utmost degree over the whole
surface of the body. Increased serous exhalation takes place from
the serous membranes also: whence, hydrothorax, hydro-peri-
cardium, and ascites: one or other of which is almost invariably
present when there is much external dropsy.
2. Discoloration of the face. If the complexion was originally
florid, it becomes purple or deep violet, on the centre of the cheeks,
the end of the nose, and the lips, with intumescence of the latter,
while the intermediate parts are pallid and sallow. Jf originally
pale, it becomes cadaverously exsanguine, and has a dusky, leaden
or venous cast, especially around the eyes. The lips are either
livid, or very pale. Lividity sometimes shows itself in the extremi-
ties as well as in the face.
3. Congestion of the brain. This produces the usual symptoms
of passive cerebral congestion, and of the corresponding form of
apoplexy; namely, dull headache, felt principally along the course
of the great sinuses ; hebetude of the mental faculties ; stupor, con-
vulsions, and eventually complete coma. It is not unusual for
these symptoms to supervene a few days before the fatal termina-
tion. Sometimes they depend, not on congestion alone, but partly
also on serous effusion into the ventricles, or on the surface, result-
ing from the congestion ; sometimes, again, the congestion ends in
sanguineous apoplexy, of which I have seen several instances.
Whence it is incorrect to suppose that this catastrophe is peculiar
to hypertrophy of the heart.
4. Injection of the mucous membranes. It is common to find
them after death so vascular as to present the appearance of in-
flammation. This is especially the case in the stomach and intes-
tines, and it is- necessary to be aware of the circumstance, in order to
guard against the error of attributing the redness to inflammation.
5. Passive hemorrhage. This takes place from the lungs, as
already stated: also from the nose, the stomach, the intestines, the
uterus, and more rarely from the bladder. It results from engorge-
ment of the mucous membranes. The effusion consists of dark
blood exuding in small quantities. When from the stomach, and
not immediately ejected, it has occasionally the appearance of coffee
grounds, in consequence of being exposed to the coagulating action
of the gastric juice. In the intestines, it is often blackened by the
intestinal acids, — the carbonic, acetic, and sulphuretted hydrogen.
6. Congestion and enlargement of the liver. This is so com-
302
HOPE ON DISEASES OF THE HEART.
mon a consequence of retardation of the blood on the right side of
the heart, that few persons so affected in any considerable degree,
are exempt from it. This has, I believe, been almost entirely over-
looked by authors on the diseases of the heart, and it is still very
little known. By the obstruction which it occasions in the system
of the vena porta, it leads to ascites and jaundice ; also eminently
favours hasmetemesis, intestinal hemorrhage, piles, and, though in-
directly, uterine hemorrhage, — many cases of which I have found
to be obstinate till the hepatic enlargement was reduced by mer-
cury and aperients. This latter fact has been noticed by Dr.
Locock.
7. Angina of the heart may occur as an adventitious complica-
tion of dilatation, no less than of hypertrophy (p. 267).
Such are the general signs of dilatation of the ventricles. I may
here mention that I have met with two or three cases in which di-
latation of the left ventricle caused mitral regurgitation, with mur-
mur, simply by rendering the orifice too large to admit of its being
closed by the valve. The first case which drew my attention to
the fact was that of a horse, which Mr. Field, the eminent veteri-
nary surgeon, requested me to see. It presented the usual murmur
of mitral regurgitation, and the small, weak, irregular, unequal, and
intermittent pulse characteristic of that affection. On post-mortem
examination, Mr. Field pronounced the mitral valve to be healthy,
but too small to close the orifice, in consequence of the latter being
enormously dilated, in connexion with general dilatation of the
ventricle.
In another case, a gentleman, he co?npletely recovered from mi-
tral regurgitation ivith murmur, and most severe general symp-
toms. Whence I infer that the regurgitation resulted from great
dilatation, which was a leading feature of his case, and was removed
by the treatment presently to be described. In a third case, what
seems to be a similar affection, is in progress of cure.
[Regurgitation through the mitral orifice in dilatation is of frequent oc-
currence. This regurgitation also frequently occurs when the heart is
momentarily surcharged by blood, in which case the valves close the orifice
imperfectly. — P.]
General Signs of Dilatation of the Right Ventricle in particular.
The signs which Corvisart regards as the most certain, are,
greater dyspnoea than in affections of the left ventricle, a more
marked serous diathesis, more frequent haemoptysis, and a greater
lividity of the face, sometimes reaching a dark violet hue. There
is no doubt that these may be effects of dilatation of the right ven-
tricle; but they are not indicative of that affection in particular,
because they are produced equally by hypertrophy with dilatation
of the same cavity, and by valvular disease on the left side of the
heart, especially mitral contraction and regurgitation. As Corvi-
sart was a total stranger to the latter, I have little doubt that, in
SIGNS AND DIAGNOSIS OF DILATATION. 303
many of his cases, the symptoms which he ascribed to dilatation of
the right ventricle, really belonged to the valvular disease. In any
of these affections the colour is not an essential sign ; for it depends,
as I have repeatedly explained, upon the original complexion ; and
so far from being always livid or purple, it is very common, in
cases of great dilatation of the right ventricle, no less than of the
left, to see the face deadly pale, and the lips exsanguine.
The sign which, with Laennec, I think the most constant and
characteristic of the equivocal signs of dilatation of the right ca-
vities, is, permanent turgescence of the external jugular veins,
without sensible pulsation. This turgescence does not disappear
when the vein is compressed at the upper part of the neck, and the
influx of blood thus prevented.
Although all these signs of dilatation of the right ventricle are
equivocal of themselves, they have some weight when coinciding
with the evidence of auscultation ; and by the two classes of signs
combined, dilatation of the right ventricle, when considerable, may
often be detected with tolerable success. I must admit, however,
that the differential diagnosis is of little importance, provided we
can detect that there is dilatation somewhere, which is generally
very possible. Whether the dilatation be connected with valvu-
lar contraction on the left side of the heart, is an ulterior question,
to be determined by ascertaining whether there exist the charac-
teristic signs of that contraction" (Vid. the chapter on Disease of
the Valves.)
General Signs of Dilatation of the Auricles.
This affection presents no general signs distinguishable from
those of the disease in the corresponding ventricle or valve to which
it owes its origin ; but its existence may safely be inferred when
the valve in question is either much obstructed, or permanently
open ; or when, from any cause, there is great retardation of blood
in the ventricle.
Physical Signs. — The rationale of the impulse and sounds of
Dilatation are explained at p. 93. The signs of the two first va-
rieties of dilatation ; namely, Dilatation with Hypertrophy, and
Simple Dilatation, that is, with a natural thickness of the walls,
are given in the chapter on Hypertrophy, under the head of Hy-
pertrophy with a predominance of Dilatation (see p. 272 for the
impulse, and p. 274 for the sounds). It only remains for me to de-
scribe the signs of the third variety, or Dilatation with Attenuation.
The Impulse. — In this variety the impulse is diminished, and
in extreme cases entirely absent, even during palpitation. When
felt, it is only a brief percussion of the thoracic parietes, not ele-
vating the ear. When the dilatation is great, the impulse is a little
lower down than natural. It sometimes happens that, of several
beats of the heart that are heard, one only \sfelt, and if this is
vigorous, it warrants a conclusion that the parietes are little attenu-
304 HOPE ON DTSEASES OF THE HEART.
ated. Though Laennec does not make this observation, I have
assured myself of its accuracy by numerous post-mortem examina-
tions. When the impulse in any form of dilatation is felt over the
lower part of the sternum, it denotes dilatation of the right ven-
tricle, but not with certainty.
The Sounds. — When the walls of the ventricles are merely thin
without being dilated, the first sound is louder, shorter, and clearer
than natural : it approximates in its character to the second sound,
— that produced by the extension of the semilunar valves, and
which is analogous to the flapping of a pair of bellows, or a gentle
tap on the hand with a finger. When there is dilatation with
attenuation, even in a moderate degree, the first sound becomes
almost the same, and nearly as strong, as the second ; and, finally,
when the dilatation is considerable, the two sounds cannot be dis-
tinguished either by their nature or intensity, but solely by their
respective situations, (the first over the lower half of the ventricles,
and the second over the semilunar valves, opposite to the lower
edge of the third rib, and thence up the great arteries,) and by their
respective relations of synchronism or anachronism with the arte-
rial pulse : and, as the pulse in remote arteries, as the radial, is, in
dilatation and other diseases of the heart retarding the circulation,
later than the ventricular systole and first sound, in a degree greater
than natural, the pulse of the carotid or subclavian should be felt.
The second sound in dilatation is increased, except when the heart
is enfeebled by dilatation with attenuation or softening.
In proportion as the sounds of the heart are louder, they are
audible, caeteris paribus, at a greater distance over the chest : ac-
cordingly, M. Laennec has proposed a scale by which the extent is
made an index of the degree of dilatation and attenuation. Before
describing this scale and showing its fallaciousness, it is necessary
to acquaint the reader with the range of the sounds in the natural
state.
In a healthy man, of medium stoutness, and whose heart is in the
best proportions, the sounds, according to Laennec, are audible in
the precordial region alone; that is, in the space comprised be-
tween the cartilages of the 4th and 7th left ribs, and underneath
the inferior half of the sternum ; also, if the sternum be short, in
the epigastrium. In the first edition of this work I expressed my
opinion that they might be heard beyond this range. I have subse-
quently assured myself that there are very few cases in which the
second sound cannot be traced along the course of the ascending
aorta and pulmonary, and heard above the corresponding clavicle
on either side, — a fact very intelligible since it has been demonstrated
by my experiments, (p. 48,) that the second sound is occasioned by
the semilunar valves. That its transmission to the clavicles takes
place principally through the medium of the aorta and pulmonary,
is countenanced by a case, brought to me by Dr. Blundell, in which
an aneurism of the ascending aorta, pulsating between the second
and third right ribs, had pulled the aorta, and with it the pulmonary
SIGNS AND DIAGNOSIS OF DILATATION. 305
artery, very much to the right side ; whence the second sound
could not be traced along the natural course of the pulmonary artery,
nor scarcely heard above the left clavicle ; while, above the right,
it was perfectly distinct. There can be no doubt, however, that the
transmission is assisted by the sternum and other solids.
The sounds, explored on the heart itself, are, according to Laen-
nec, " similar and equal on the two sides, " those of the right being
most audible under the sternum, and those of the left, under the
cartilages of the ribs. I have myself, however, strong reasons to
believe that the first sound of the right ventricle is shorter and
smarter, (i. e. more flapping,) than that of the left ; because the
walls of the right ventricle are thinner, and their state, therefore,
more analogous to that of dilatation (See Conclusions on the
Sounds, p. 77).
When the sounds are audible beyond the limits mentioned by
Laennec, they are heard successively in the following places, consti-
tuting his scale alluded to : viz.
1st. Along the sternum and at the left superior anterior part of
the chest as high as the clavicle ;
2d. Over the same extent on the right side ;
3d. The left side of the chest, from the axilla to the region of
the stomach ;
4th. The right side over the same extent ;
5th. The posterior left side of the chest ;
6th. The posterior right side.
The intensity of the sound is progressively less, according to
Laennec, in the succession indicated, provided the parts around the
heart are in the same relative states. But there are so many diver-
sities in these, which may interfere with the order described, that I
have found the scale of M. .Laennec of little practical utility in esti-
mating the degree of dilatation. Thus, in very fat subjects in whom
the impulse of the heart is not perceptible to the hand, the space over
which its sounds can be heard by the cylinder, is much more lim-
ited than natural : Laennec has even found them confined, in some
instances, to about a square inch, though I cannot say that this has
occurred to myself.1 On the other hand, "in meagre persons,"
says Laennec, "in those who are narrow-chested, and in children,"
the sounds are audible much further : namely, " over the two inferior
thirds, or even three-fourths of the sternum, sometimes even over
the whole of that bone and at the left anterior superior part of the
chest as high as the clavicle; often, also, though less distinctly,
below the right clavicle." In very meagre subjects I have heard
1 M. Bouillaud has more recently expressed a similar opinion. "In very
fat subjects, the sounds of the heart are less extensively audible than in the
meagre: but I dare affirm that M. Laennec has deviated a little from the
truth in saying — ' that the space over which they may be heard with the
aid of the cylinder, is sometimes confined to a surface of aboutasquaie inch.' "
— (Bouillaud, du Cceur, i. 107.)
11— a 20 hope
306 HOPE ON DISEASES OF THE HEART.
them over the whole chest, both posteriorly and anteriorly.1 I have
also frequently heard the first sound below the umbilicus, when
exploring pregnancy. Now, as it is almost impossible to make an
exact estimate of the degree in which stoutness limits, and leanness,
&c. extend the range of the sounds, this range is not a sure criterion
of the degree of dilatation.
Again, a lung in any way consolidated, whether by hepatization,
tubercles, or compression by fluid in the cavity of the pleura, trans-
mits the sounds of the heart more strongly than a lung that is sound
and permeable to air — a phenomenon explicable on the principle
that dense bodies are the best conductors of sound. The effect is
the same though there be cavities in a tuberculous lung ; for the
sound is transmitted, not through the cavities, but through their
walls, which are denser than healthy pulmonary substance.
Under these various circumstances, then, the sounds are irregu-
larly propagated, and the progressive scale of Laennec is interfered
with. For instance, if the right lung be consolidated, the sounds
will be more audible on that side than on the left.
My own mode of estimating the degree of dilatation, is by observ-
ing how far the first sound resembles the second, and comparing the
intensity of the first, heard immediately over the ventricle affected,
with what I conceive, from experience, would be its intensity in the
same subject if the heart were healthy. I used formerly to corro-
borate the estimate, if necessary, by the scale of Laennec; making
allowance, as far as is practicable, for stoutness, leanness, youth,
pulmonary condensation, (fee. ; but the experience of the last seven
years having more strongly convinced me of the practical inutility
of that plan, I now seldom resort to it.
The manner in which I judge of attenuation by the first sound,
is less by its loudness, than by its greater shortness and clearness —
its more complete assimilation to the second sound ; for I think it
is often louder in dilatation with hypertrophy, or even with a natural
thickness of the parietes, than with attenuation. This opinion is op-
posed to that of Laennec, who '• thinks he may regard it as constant,
that the extent over which the beats of the heart are audible is in the
direct ratio of the feebleness and thinness of its walls." So far is
this from being perfectly true, that I have met with cases in which
the heart was dilated and attenuated to the extreme, yet the first
sound was feeble. Since broaching this opinion in the first edition,
innumerable observations have assured me of its accuracy. Nor
should we expect it to be otherwise in such cases ; for, when the
1 This observation also has been corroborated by M. Bouillaud in his recent
work; "I can certify," says he, "that in the subjects belonging to the cate-
gory specified by Laennec, I have, not once only, but many hundred times,
heard the sounds of the heart, not only in the regrons.indicated by Laennec,
but in all other parts of the chest, without excepting even the right posterior
region : also, at the lateral parts of the neck, a situation where they are very
often almost as loud as in the precordial region itself." " The transmission
of the sounds," he continues, "takes place through the walls of the chest
and the contained organs: also, through the vertebral column, which is ar-
ticulated with the ribs" (Traite, i. 107).
SIGNS AND DIAGNOSIS OF DILATATION. 307
heart, from extreme dilatation, is too feeble to contract smartly, its
sounds must necessarily be weak. Hence they are so in ramol-
lissement, and in the moments preceding dissolution.
[Almost all writers on the heart endeavour to convey an idea of the first
and second sounds of the heart by certain articulate symbols. The French,
to express this double sound, call it a " Tic-lac," -which is certainly a very
wrong sounding word to convey a notion of this sound. Dr. C. J. B. Wil-
liams employs the word "lubb-dup," which is a most happy ariiculate sym-
bol. The first word lubb giving the idea of a protracted first sound in
contrast with the short sound of the second, as expressed by the word dup.
Dr. W. very justly remarks, that, " if we would be a little more consistent
in our rules of pronunciation, we might often give the sounds of the heart,
healthy and morbid, in language of this kind, with more ease and precision
than by description or comparisons." In the description of the pathological
states of the heart, this ingenious writer has adopted this plan to express
some of the morbid sounds. Thus, in dilatation of the heart, where the first
sound so nearly resembles the second, that it is very often difficult to distin-
guish between them unless a finger be applied upon the carotid artery at the
same moment that the ear is placed upon the praecordial space, in order to
determine which sound coincides with the puise, he proposes the word lup-
tupxo express the abnormal sound, instead of that first mentioned (lubb-dup),
of the healthy heart.
The walls of the heart in dilatation being extended into a thin layer of
muscle, their contractions are short, abrupt, and produce loud, clear sounds,
but do not create a marked impulse; even when the heart is excited by pal-
pitation, the pulsations do not raise the thoracic parietes or produce heav-
ing of the chest, as seen in hypertrophy, or even in the excited healthy
heart.— P.]
Resonance on Percussion. — The resonance of the praecordial
region on percussion is diminished by dilatation. The dulness is
situated rather lower than natural, and, as it is always in proportion
to the increase of volume of the heart, it is greatest in hypertrophy
with dilatation. When it extends over the inferior part of the
sternum, it denotes dilatation of the right ventricle.
Dulness of the praecordial region on percussion may exist inde-
pendent of enlargement of the heart; namely, when the anterior
borders of the lungs are hepatized, and extend in front of the heart.
I have met with a case of this kind in which the hepatized borders,
forced completely over the heart by emphysema of the posterior
parts, not only caused defective resonance, but prevented the impulse
of an enormously hypertrophous heart from being perceptible.
This, however, is a rare source of fallacy. On the contrary,
dilatation may not occasion deficient resonance when the lungs are
emphysematous, and their anterior margins are forced between the
organ and the sternum; but this source of fallacy may be in a
great measure removed by making percussion while the patient
inclines forward and makes a complete expiration, by which the
lungs are withdrawn, and the heart allowed to gravitate forward.
I have seen the heart depressed into the epigastrium by great
emphysema. I have also seen it thrown over to the opposite side
of the sternum when the emphysema was confined to the left
lung— especially if the right was condensed and contracted.
20*
308
HOPE ON DISEASES OP THE HEART.
[" The sound on percussion will be dull in the region of the heart, in some
proportion to the extent of the disease; more extensively so than is usual in
simple hypertrophy", but less than in dilated hypertrophy, in which the greater
size to which the organ attains, and its flaccidity, which exists as in dilata-
tion, brings a larger surface in apposition to the walls of the chest. To a
certain degree we may, by the position of these signs, determine which com-
partment of the heart is most dilated, those of the left ventricle being, as
Laennec pointed out, situated between the cartilages of the fifth and seventh
ribs, and those of the right at the lower half of the sternum, and in the epi-
gastrium. A dilated right ventricle, however, sometimes extends far to the
left of the sternum, carrying the left ventricle behind and above it away
from the walls of the chest, which, as in dilated hypertrophy, may prevent
the impulse and sounds of the latter from being readily distinguished from
those of the right. Under these circumstances a complete expiration and
leaning forwards to the left, will sometimes bring the heart into more com-
plete contact with the walls of the chest, and give the stronger impulse and
duller sound somewhere under the left breast. On the other hand, when the
left ventricle is dilated, the impulse is felt lower than usual ; but it does not
displace materially the position of the right ventricle, which may be heard
and felt at the sternum, in consequence of their greater loudness, and the
large size of the body in which they are produced, the sounds are heard over
a greater extent of the chest than usual ; but I cannot agree with Laennec,
that this extent is so perceptibly proportioned to the degree of the dilatation
as to be an exact measure of it. The transmission of the sound through the
lungs may be so much modified by even temporary conditions of the lungs
(and much more so by consolidation, hypertrophy, or emphysema) that the
distinctness of the sounds in different parts of the chest depends as much
on these organs as on the intensity of the sounds themselves." — C. J. B.
Williams's Lectures, tf-c. — P.]
Physical Signs of Dilatation of the Auricles. — Auscultation
has not hitherto supplied any direct signs of dilatation of the au-
ricles ; but as this affection is, in general, the consequence of dis-
ease of the valves, and of enlargement of the ventricles impeding
the circulation through the heart, its existence may be inferred from
the physical" signs of these affections. Thus, when there is a con-
tracted, and, still more, a permanently open state of either auricu-
lo-ventricular orifice, dilatation of the corresponding auricule is
almost certain : and when there is hypertrophy and dilatation of the
right ventricle with much jugular congestion, dilatation of the right
auricle is highly probable.
[" Extreme dilatation of the auricle, particularly the right, may caUse dul-
ness on percussion at the middle of the sternum, and on either side of it; in
fact, it only adds to the extent of the dulness produced by the enlargement
of the ventricle which is conjoined with it. Laennec taught that dilatation
of the auricles increased the loudness of the second sound; and although
his view of the cause of this is totally erroneous, I think I can from expe-
rience confirm the fact, that the second sound has been sometimes unusually
distinct at the middle of the sternum and on either side of it, in cases in
which examination after death showed one or both of the auricles to be di-
lated. The second sound is, you know, produced by the flapping tension of
both sets of semilunar valves ; and although the diluted auricles which lie
close to these valves do not increase the sound, they transmit it to the front
wall of the chest better than the spongy tissue of the lung, which generally
intervenes, could do. I once saw a double pulsation between the third and
fourth right ribs, close to the sternum, which I was led to ascribe to a greatly
dilated right auricle. The same double pulse was in the jugular veins ; and
PROGRESS OF DILATATION. 309
I believe, with Laennec, very commonly attend extreme dilatation of the two
right compartments of the heart, there being, in such a case, pretty free re-
gurgitation through the auriculo-ventricular orifice." — C. J. B. Williams's
Lectures, <§-c. — P.]
SECTION V.— Progress, Terminations and Prognosis of Dilatation.
Ill many persons the heart, without being dilated, has naturally-
thin walls ; that is to say, (to assume a standard of comparison for
an object which cannot have any fixed one,) the walls of the left
ventricle are not, at the utmost, more than twice the thickness of
those of the right. This state presents signs similar to those of di-
latation, but in a less degree; namely, the impulse is diminished,
the first sound is short and clear, and both sounds are more exten-
sively audible than natural. Individuals so affected may live for a
great number of years, even to an extreme old age, in a state of
tolerably good health : it is only to be remarked that this conforma-
tion is in general accompanied with a delicate constitution, a slim
stature, and small muscles. In fevers and diseases of the respira-
tory organs, the individuals in question experience, casteris paribus,
greater dyspnoea than others. If such a conformation augments,
even slightly, a dilatation of the heart is the result.
A slight degree of dilatation is not a very formidable affection.
The dyspnoea is sometimes not so great as to deserve the name of
morbid: but the patient has simply a shorter respiration than most
men, he more readily loses breath, and he experiences palpitations
from much slighter causes. With these slight symptoms, however,
he generally exhibits some delicacy of general health, and often
presents a sallow, cachectic appearance.
This state (which is that of a great number of asthmatics) may
subsist very long without occasioning any disorder of a serious
nature; it may remain without making progress for a great num-
ber of years, and it does not always prevent the patient from attain-
ing an extreme old age.
When dilatation has advanced so far as to occasion morbid dys-
pnoea, it has a constant tendency to increase, unless the circulation
be kept tranquil by a very quiet life and judicious medical treat-
ment, when necessary. With these precautions, the disease may
commonly be cured ; and, when not, it may generally be kept sta-
tionary, sometimes for an indefinite period, if not exasperated by
fevers, inflammations, dyspepsia, or other affections, which, by hur-
rying: the circulation, are eminently prejudicial.
When dropsy comes on, and, after having been removed by re-
medies, constantly shows a disposition to return, we may know
that the dilatation tends to its fatal termination ; and although the
patient may sometimes rally from five, six, or even more attacks,
he generally sinks in the course of one or two years, or less. The
progress of dilatation with hypertrophy is much more rapid, as
already explained in the chapter on Hypertrophy.
Prognosis. — The general prognosis is founded on the above con-
310 HOPE ON DISEASES OF THE HEART.
siderations, and is favourable so far as life is immediately concern-
ed. The particular prognosis depends upon the degree of severity
of the symptoms and the constitution of the patient. Dilatation
with attenuation, and especially with softening, is the most destruc-
tive form.
SECTION VI.— Treatment of Dilatation.
The treatment of dilatation with increased power of the heart,
that is, with hypertrophy, is described in the chapter on Hyper-
trophy. In this place I have only to speak of the treatment of dila-
tation with diminished power, that is, with attenuation, and some-
times with a natural thickness of the parietes.
The first indication is. to remove, if possible, the exciting cause
of the dilatation ; and if this be done before the disease has proceed-
ed to such an extent as entirely to deprive the muscular fibre of its
resilience and elasticity, these faculties come into operation and
restore the organ to its natural size. Accordingly, if the cause be
an obstruction in the pulmonary circulation, as that produced by
hydrothorax, chronic bronchitis, emphysema, asthma, the use of
wind-instruments, ventriloquism, &c, the attention must be prima-
rily directed to the removal of these affections and the prohibition
of these habits. If the cause be too violent exercises, mental emo-
tions, inebriety, dissipation, occupations which, by placing the
patient in a constrained posture, prevent the free circulation of the
blood, as the professions of shoemaker or tailor,&c..thepernicious ex-
ercises, habits or professions must be abandoned and the mind calmed.
All the causes enumerated being of a temporary nature, the di-
latation resulting from them, if not inveterate, can generally be re-
moved. Of this I feel assured from careful observation during the
last fifteen years, though I am aware that Laennec and many others
regard the disease as incurable. But when the cause is permanent,
as the contraction of an orifice of the heart, or a natural or acquired
and long-established feebleness of the organ in proportion to its
function, a complete cure of the dilatation is scarcely to be expected;
but it may often be diminished, or kept stationary, and the life of
the patient may sometimes be prolonged even to its extreme limits.
In such cases, therefore, the practitioner should steadily and perse-
veringly pursue a palliative and prophylactic treatment, having
first discarded from his mind the impression, no less erroneous in
itself than detrimental to the progress of medical science, that or-
ganic diseases of the heart are necessarily fatal, and that therefore
all treatment is unavailing.
The circulation should be kept as tranquil as possible by a strictly
quiet life, and a moderate, unstimulating diet. The food, however,
should be nutritious, comprising slightly under-dressed animal
food, principally mutton and beef, twice a day, at breakfast and din-
ner, in order to keep the muscular system in general, and that of
the heart in particular, in good tone. The same object may be
promoted by a clear, dry, bracing air, as that of Brighton, and the
TREATMENT OF DILATATION. 311
shower-bath ; from both of which I have seen the best effects re-
sult. Neither of them, however, have I found to suit those patients
who have great pulmonary congestion with copious expectoration ;
as such require a warm, humid atmosphere to favour expectoration
and the cutaneous function, and they cannot bear the shower-bath,
on account of its determining too much from the surface to the
heart and great vessels. Neither do they well bear opiates ; as
these remedies partly occasion diminished mucous secretion, and
partly, accumulation of that already secreted ; both of which cir-
cumstances increase the dyspnoea.
The general health and strength may likewise be improved by
the occasional exhibition of bitters, mineral acids, and chalybeates,
with aromatics. The preparations of iron in full doses, and in
courses of from four to six weeks, with aloetic aperients and ani-
mal diet, are imperatively required and singularly beneficial if an
anaemic state prevails. The stomach should be kept in good or-
der ; as its derangements — even a little flatulence or acidity, have
a surprising effect in disturbing the action of the heart. The same
may be said of the biliary secretion. When there are hysterical
symptoms, antispasmodics, particularly thepilula galbani composita,
and valerian, are very useful adjuncts to other remedies, due atten-
tion being also paid to the catamenia. If there be much nervous
excitability with palpitation, sedatives, as digitalis, hyoscyamus, &c.
may be employed.
Febrile and inflammatory affections of every kind, but particu-
larly inflammation of the lungs and bronchia, should be sedulously
guarded against, and, when occurring, should be promptly treated.
Even a slight pulmonary catarrh should be viewed as a serious
affection. To prevent colds, and relieve the heart by keeping up
the circulation on the surface, flannel next to the skin is almost
indispensable; and if the patient be chilly, as is frequently the case
in dilatation, a jacket of wash-leather should be worn over the flan-
nel during the winter. In short, the patient should be so clothed
as to prevent chilliness, both within doors and out.
Attacks of dyspnoea are best relieved by immersing all the extre-
mities in warm water, a blanket being thrown round the patient to
promote perspiration, and fresh cool air being admitted to satisfy
the craving for breath. While this is being done, he should take
an antispasmodic draught composed of aether, laudanum, camphor,
ammonia and assafoetida, combined according to circumstances.1
It may be repeated two or three times, at intervals of from half an
hour to an hour, according to circumstances.
Blood-letting should not be resorted to in dilatation with defi-
cient power of the heart, during the paroxysm, and merely for the
purpose of relieving it. The abstraction of a small quantity has
not the effect, and that of a large is inadmissible, as it does more
injury by increasing the debility of the heart, than it does good by
lightening the circulation. Consequently, an ultimate aggravation
1 Vid. for particulars, Treatment of Disease of the Valves,
312 HOLJE ON DISEASES OF THE HEART.
of dyspnoea is the result. More than once, I have seen a large and
indiscreet blood-letting fatal ; as the patient could not rally from
the exhaustion produced by the attack of dyspnoea to which that
from the depletion has been superadded. If there be an absolute
necessity for blood-letting, that is, if the dyspnoea be constant, and
cannot be relieved by any other means, the quantity drawn should
not exceed six ounces at one time, and it should be drawn very
slowly, and during the intervals or remission of the fits. In this
way the bleeding may be repeated, if necessary, every one, two or
three months, provided it does not diminish, but, rather, increases
the strength of the patient. It must, however, be clearly under-
stood that bleeding does not properly constitute a part of the treat-
ment for dilatation with diminished power, but is an exception to
the general rule.
For the treatment of dropsy, cough, (fee, I refer the reader to
the chapter on Diseases of the Valves.
CHAPTER III.
PARTIAL DILATATION OR REAL ANEURISM OF THE HEART.
The heart may be affected with real aneurism. In a young
negro, who died suffocated, Corvisart found the left ventricle sur-
mounted by a tumour almost as voluminous as the ventricle itself,
containing several layers of rather dense lymph perfectly similar to
those of aneurism of the limbs, and communicating with the cavity
of the ventricle by a narrow, smooth, and polished aperture (Essai
sur les Maladies du Coeur, p. 283). M. Berard has recorded two
similar cases, except that the tumours were only as large as ducks'
eggs. In one, a portion of the sac was formed by the pericardium
and fibrinous layers within, the muscular substance being entirely
deficient. The general aspect of one of these preparations, ex-
amined by Laennec, led him to believe that aneurisms of this kind
result from ulcerations of the internal surface of the ventricles. It
will presently appear that this opinion is only partially correct.
Four or five cases of the disease have occurred to myself. In one,
(Brown,) steatomatous degeneration had caused the formation of a
canal from the aorta, underneath one of the sigmoid valves and the
internal membrane of the left ventricle, leading to an aneurism, as
large as a nut, in the substance of the auriculo-ventricular septum.
A similar case occurred subsequently in St. George's Hospital. A
third, in which the aneurism was ossified, is delineated in Fig. 20.
In the second case, the second sound was accompanied with a bel-
lows-murmur. In the first and third cases, the physical signs were
not noticed ; yet there must necessarily have been a murmur with
the second sound from regurgitation into the left ventricle, and that
such was actually the case in Brown, is almost proved by {he jerk-
REAL ANEURISM OF THE LEFT VENTRICLE. 313
ing pulse, — this state being invariably present in considerable aortic
regurgitation. The general signs, in all the cases, were those of
organic disease of the heart.
Mr. Thurnam has published a valuable paper in the Medico-
Chirurg. Trans, vol. xxi, 1838, in which he has collected together
seventy-four cases, thirteen of which, from the London and Chat-
ham Museums, had not previously been described.
In fifty-eight of the seventy-four, the disease was situated in the
left ventricle. In no instance has it been found in the right; which
is apparently attributable to this ventricle being less subject to in-
flammation, and to great distensive pressure.
The following is an abstract of Mr. Thu mam's history of the
fifty-eight cases in the left ventricle, to which he applies "the nu-
merical method as rigorously as may be."
Lateral Aneurism of the Left Ventricle. — "Lateral aneurism of
the left ventricle is met with under two principal forms. Thus it
may be either unattended by any external deformity of the heart,
and confined altogether to the ventricular walls : or it may present
itself in the form of a tumour growing from the exterior of the
organ, and in size varying from that of a nut to that of the heart
itself. In sixty-seven aneurisms occurring in the fifty-eight cases,
thirty-five were attended by tumour; in nineteen there was no
tumour: and in the remaining thirteen, it is doubtful whether
tumour existed or not ; although, from the small size of the sacs
in these latter cases, it is probable that the disease scarcely extended
beyond the surface of the ventricle."' l
"The size of the aneurismal sacs varies greatly: thus, in nine
cases, their size might be compared to thai of nuts; in twenty, to
that of walnuts; in seven, to fowls' egos; in fourteen, to oranges ;
and in nine cases, it almost or quite equalled that of the healthy
heart itself. In one of these last named cases, the tumour had
nearly presented externally. When the disease has been of some
standing, and the sac lias attained to a certain size, it usually opens
into the ventricle by a mouth, the diameter of which is narrow,
['"The heart is occasionally the subject of hemorrhagic effusion, either
in the form of patches or petechia?, on one or both of its surfaces, as has
sometimes been observed both in land and sea scurvy, and in putrid fevers;
or blood may be poured out in larger quantities, and either infiltrated into the
very substance of the organ, or collected into a factitious cavity formed by
the separation and laceration of its fibres, constituting the disease spoken of
by some authors under the title of apoplexy of the heart. Cruveilhier, who
has seen many instances of it, believes it to be much more often than ulcera-
tion and inflammation the cause of rupture of the heart. Hitherto it has
only been observed in the left ventricle, and generally in connexion with
hypertrophy.
"The muscular fibres are found quite broken down and displaced, and a
coagulum occupies the cavity so formed, and with it, at a later period, puru-
lent matter appears to be mixed. Perforation towards the inner or outer sur-
face of the organ seems to be a frequent result, as is likewise the false
consecutive aneurism described by Bheschet." — Dr. Jotf Tweedie's Li-
brary.—P.']
314 HOPE ON DISEASES OF THE HEART.
relatively to that of the sac itself; and the lips of which, like those
of old arterial aneurisms, are generally projecting, well defined,
and formed of a dense fibrous tissue. This kind of opening to the
sac was present in at least twenty-five of the cases ; whilst in nine-
teen others, which were mostly incipient, the mouths were as wide
or wider than any other part of the sac, and no such projecting lips
existed.
" With respect to the tissues of the heart engaged in the forma-
tion of the aneurismal sac, a careful analysis of the cases would
seem to show, that in fifteen, the sacs were formed by the muscular
fibres and pericardium ; in four, by the endocardium and pericar-
dium only; in twenty-five, by all of the structures entering into
the composition of the walls of the heart; whilst, in twenty-three
cases, the disease was either too far advanced, or the data are in-
sufficient, to enable us to assign them to their proper places. The
aneurismal sacs had in some cases undergone changes and trans-
formations of different kinds ; thus, in two cases, they are stated to
have assumed a steatomatous structure; in three, a cartilaginous
one ; which latter change, in six others, was combined with a more
or less advanced calcareous or osseous degeneration.
" In twenty-one cases, and probably in a still greater number, the
sac had become strengthened by adhesion to the loose or fibrous
layer of the pericardium; and in all these instances, the disease
had advanced to the extent of producing tumour on the external
surface of the heart."
"In six cases, in none of which had adhesion taken place be-
tween the aneurismal portion of the heart and the pericardium, and
in which the aneurism scarcely, if at all, projected beyond the sur-
face of the ventricle, a rupture of the sac had occurred which had
led to a fatal extravasation of blood into the pericardium. In one
case only does rupture appear to have occurred when there was
the adhesion alluded to, and in this instance the left pleura was the
seat of the hemorrhage."
" As regards the contents of the sacs, in twenty-three cases, which
were chiefly those furnished with constricted mouths, and which
were of considerable size, there was found a greater or less quan-
tity of laminated coagula; seventeen, either apparently of less
standing, or situated more in the direct channel of the blood, con-
tained simple amorphous coagula; whilst nineteen appear to have
been found empty after death. In three other cases, the contents
were, in one, a hollow globular coagulum ; in two others, simple
fibrinous ones, evidently of old date.
" It would appear that no part of the left ventricle is exempt
from becoming the seat of aneurism. Although a more extended
acquaintance with cases than was possessed by-M. Breschet at the
time when he wrote on this subject, shows that this author was in
error when he supposed the disease to be nearly, if not quite con-
fined to the apex of the ventricle, yet this would still appear to be
its most frequent situation. Thus the sixty-seven aneurisms which
REAL ANEURISM OF THE LEFT VENTRICLE. 315
occurred in the fifty-eight cases, omitting one case in which this is
not mentioned, may, as regards situation, be thus distributed; at or
near the apex of the ventricle, twenty-seven ; in different points of
the base, twenty-one ; in intermediate portions of the lateral walls,
fifteen ; in the interventricular septum, three. Of the cases in
which the sac was seated at the base, four, which occurred to Dr.
Hope, are remarkable from having opened both into the ventricle
and into the aorta. Dr. Hope is of opinion that 'steatomatous
degeneration had caused the formation of a canal from the aorta
underneath one of the sigmoid valves and the internal membrane of
the left ventricle,' and that, in this way, an aneurism had origi-
nated, which had ultimately opened into the cavity of the heart.
It would, however, appear to me more probable, that the aneurisms
had originally been formed in the ventricle, and had subsequently
communicated with the aorta, as a consequence of the co-existent
disease of the valves of that vessel ; and I may observe, that this
view would appear to be supported by four other cases in which
the sacs had precisely the same situation, but in winch there was
no communication with the aorta. In the last of these cases, the
preparation of which is in the museum at St. Bartholomew's Hos-
pital, the contiguity of the aneurism to the aorta is such as to have
led to its being described in the MS. catalogue as an aneurism of
that vessel. Of the three cases in which the aneurism had its seat
in the septum of the ventricles, one is only briefly alluded to by M.
Cruveilhier as occupying its lower half, and as threatening to burst
into the right ventricle. In another of these cases, recorded by
Laennec, an accidental ulcerated canal had been formed in the
highest part of the septum, and was accompanied by what would
appear to have been a minute aneurism, containing fibrinous
coagula. It is well known to anatomists, that the highest part of
the septum, which occupies the angle between the posterior and
ri^ht aortic valves, and which, in some instances of congenital mal-
formation, is deficient, is in the human subject formed not of mus-
cular fibres, but simply of the endocardium of the right and left
ventricles almost in apposition, and strengthened only by the inter-
position of a little fibrous tissue continuous wijh that of the aorta."
" To conclude these observations on the situation of the aneurism
of the left ventricle, the only general conclusion that we can come
to appears to be, that the thinnest parts of its walls, or the apex and
the highest part of the base, are those which are much more fre-
quently than any others the seat of the disease.
" In general, or in fifty-two out of the fifty-eight cases, only one
aneurism existed in each ; but in four cases, two were met with in
each : in one, there were three ; and in another, four incipient aneu-
risms. In two instances, it is not improbable that two sacs, which
were originally distinct had coalesced, so as to form a single aneu-
rism; and in another case, three sacsappear to haveunitedin this way.
"An important point in the history of lateral aneurism of the
heart, is that which relates to the other lesions of this organ, which
316 HOPE ON DISEASES OF THE HEA&T.
are found to accompany it. To begin with the pericardium: in
addition to the twenty cases already alluded to in which there was
adhesion to the surface of the aneurismal tumour, we find that, in
seven cases, there was general adhesion of this membrane to the
surface of the heart; that in one, there was recent hemorrhagic
pericarditis; and that in three, there was dropsy of this cavity. In
twelve cases, the endocardium is stated to have undergone different
changes of structure ; so as to have become either white, opake, or
thickened in the immediate neighbourhood of the sacs, or even
more extensively ; and in one case, there was a minute deposit of
calcareous matter either in or beneath this membrane. The mus-
cular substance of the ventricle was, in at the least nine cases, the seat
of more or less extensive fibro-cellular degeneration, which was
generally most marked around the sacs : in one case, there was a
cartilaginous transformation ; and in another, induration from a
non-specified cause. In one instance, the walls of the ventricles
are said to have been the seat of ' lardaceous tumours,' and in
another, of extensively diffused suppuration. In numerous cases,
there was a marked atrophy either of the fleshy columns which
form the pillars of the mitral valve, or of the smaller ones which
constitute the net-work on the internal surface of the ventricle.
The valves of the left cavities are stated to have been diseased in
ten cases; in five of these the mitral valve was the seat of the
lesion, and was constricted by cartilaginous or osseous deposit ; in
three, the aortic valves were diseased, and both these sets of valves
were implicated in one example. In eight cases, the valves are
reported to have been healthy ; whilst, in the remainder, their con-
dition is not mentioned.
" Respecting the pathological changes in the heart, which we
have thus seen to accompany lateral aneurism of that organ, it ap-
pears important to observe that they may almost universally be re-
garded as the effects of inflammation. With respect to a majority
of them, or those seated in the muscular tissue and pericardium,
there can, on this head, scarcely be a doubt; and although some
difference of opinion may still exist respecting the alterations which
have been alluded to as involving the endocardium and the valves,
yet they are now very generally, and I think correctly, regarded as
the consequences of inflammation. From this part of our inquiry
also, I think we can scarcely avoid drawing the inference, that
aneurism of the heart cannot be regarded as exclusively dependent
upon pathological changes in one only of the tissues entering into
the composition of this organ."
" The number of cases in which the heart is not stated to have
been the subject of some lesion, (hypertrophy, dilatation, &c.,) in
addition to the aneurism, does not exceed ten ; and in three only is
it positivelv stated to have been otherwise healthy."
As respects the influence of sex ; in forty cases, in which this is
recorded, thirty occurred in males, and ten in females. The pro-
portion thus met with in the female, is much greater than is found
REAL ANEURISM OF THE LEFT VENTRICLE. 317
to be the case in arterial aneurisms, which, according to Hodgson,
occur eight, and according to Lisfranc, eleven times oftener in the
male than in the female. Even as respects aneurism of the aorta,
the most common variety of the disease in the female, Dr. Hope
has only found the proportion to be rather larger than that indicated
by Hodgson.
" The age of the patient is either stated, or to be inferred with
tolerable accuracy, in thirty- five cases/'
"It appears, that after adult age, cardiac aneurism is not remark-
ably confined to any particular period : although it would seem to
prevail with the greatest frequency at two distinct periods, or be-
tween the ages of twenty and thirty, and again in very advanced
life. In this respect, then, we likewise find that cardiac aneurism
differs remarkably from arterial, which, according to the experi-
ence of Sir Astley Cooper, and also from an analysis of one hun-
dred and eight cases by M. Bizot,1 prevails chiefly between the ages
of thirty and fifty/5
" There can scarcelv be a doubt, that, as of other organic diseases
of the heart, so also of aneurism, — acute rheumatism, affecting this
organ, either in the form of endocarditis or of pericarditis, is to be
regarded as closely connected with the production, if not as the effi-
cient cause, of this lesion. If this view should prove to be correct,
we shall have no difficulty in explaining the greater frequency of
cardiac than of arterial aneurism during early life ; as it is well
known, that in the progress of acute rheumatism, the inflammatory
affections of the heart which have been alluded to, occur much
oftener at this than at any other period.
"The exciting cause of the disease would appear to have been
external violence, in the form of an injury of the chest, in the case
of the gondolier, a fit of violent anger in that of the nobleman, pro-
tracted mental anxiety in another instance, severe efforts on the
stage in the character of Hamlet, in the case of Talma, and in a
fifth instance, the retention of the breath during a military flogging.
" From an examination of the anatomical details, as well as of
the apparent causes of the disease, in reference to the determin-
ing of its nature, I come to the conclusion, that in twenty-two cases
out of the fifty-eight, the aneurism originated in a dilatation of all
the structures entering into the composition of the walls of the
heart; and in six, in a solution of continuity of the lining mem-
brane and inner stratum of muscular fibres, either as a consequence
of ulceration, or, what is more probable, of rupture; whilst, in the
remaining thirty cases, the disease was either too far advanced, or
the data given are insufficient to enable us to form a satisfactory
opinion on this question.
"I therefore conclude that this lesion, in by far the greater pro-
portion of cases, is of the nature of true aneurism: or that it has
its origin in the dilatation of a portion of the walls of the heart,
which has become less able to resist the distending force of the
1 Mem. de la Soc. Med. d'Obs. torn. i. p. 409. Recherches sur le Cceur et
le Systeme Arteriel,
318 HOPE ON DISEASES OP THE HEART.
blood during the ventricular systole, in consequence of organic
changes in the tissues composing it. These changes may be con •
fined, to one of these tissues, as the endocardium; or they may in-
volve that membrane and the muscular structure simultaneously;
or, lastly, they may, I believe, originate in the pericardium, and be
propagated from without, inwards. In a great majority of instances,
these changes would appear to have been the result of a more or
less active antecedent inflammation."
"In the departments of symptomatology and diagnosis, the in-
formation that we possess relative to this form of disease is less ex-
tensive and precise, than that relative to its pathology. It is probable
that, in its incipient forms, aneurism of the heart is not necessarily
attended by any derangement in the function of this organ. In
two cases, it is expressly stated that no symptoms referable to the
heart existed during life, and in these the disease was in a very
early stage.
"The mode of incursion of the disease differs remarkably in two
classes of cases. Thus in three instances the attack was sudden,
and attended with marked symptoms, analogous to those observed
in cases of rupture of the heart, when this is not directly fatal.
The most instructive of these cases is that of the nobleman, related
by Galeati, who, after a violent fit of anger, was suddenly seized
with severe prcecordial pain, orthopnoea, agitation, fear of death, a
disposition to syncope, and a vibratory, frequent, but languid pulse.1
" In cases of this description, the mode of attack, as well as the
immediate causes, would lead us to conclude that the disease is of
the nature of false aneurism from rupture.
" In the great majority of cases, however, the disease would
seem to have had a very insidious origin, and to have been only
very gradually announced by symptoms. This is what we should
be prepared to expect in cases of true aneurism ; and it may be
observed that this difference in the mode of attack in the two forms
of the disease, corresponds with, and supports the conclusion,
which, chiefly on anatomical grounds, has been already come to.
that true aneurism of the heart is much more common than false.
"In five cases, the symptoms of the disease are described gene-
rically as those of 'diseased heart.' In twenty-three cases in
which the symptoms are given in detail, these, taken in the order
of their frequency, were as follow; dyspnoea, in several instances
amounting to the severest form of orthopnosa, in fifteen cases ;
prascordial pain of different characters, in one or two cases amount-
ing merely to uneasiness, but in several others accompanied by a
sense of weight, in fourteen ; dropsy more or less extensive, in ten
cases; palpitation in nine cases; anxiety, dread of death, or rest-
lessness, in eight ; and syncope, or a disposition jto it, in three cases.
"In addition to these symptoms others are also more rarely men-
tioned ; such as cough, throbbing of the carotid arteries, pulsation
of the jugular veins, livid or blue countenance, and hemorrhage
'I have noticed the same symptoms in six or seven cases of rupture of the
aorta or of valves, (see p. 202).
REAL ANEURISM OF THE LEFT VENTRICLE. 319
from the nose and lungs. The condition of the pulse is noted
only in a few of the cases, and in seven of these it is stated to have
been feeble, sometimes in an extreme degree."
" As aneurism of the heart has seldom been met with, uncompli-
cated with other lesions of this organ, great difficulty necessarily
attends our forming any conclusions as to the general symptoms, if
any, which distinguish it."
"But in addition to the class of symptoms now alluded to, a
variety of distressing sensations in the precordial region were ex-
perienced in a great proportion of cases ; which would, to a certain
extent, serve to distinguish the disease from cases of simple dilata-
tion with or without hypertrophy. Symptoms of this description
are met with in two well-known forms of disease of the heart,
angina pectoris and valvular disease, and especially in those cases
in which there is much ossification. Now, although the group of
symptoms which are known by the name of angina pectoris, cannot
always be referred to an ossified and indurated condition of the
coronary arteries, valves, and origins of the great vessels, yet as the
best recent authorities concur in the belief that, in the majority of
cases, it is associated with these or similar changes, we shall not
perhaps be generalising too rapidly, in ascribing the uneasy sensa-
tions and pain, which are met with in these three forms of disease,
to one common cause.
" This would appear to me to consist in the irritation occasioned
by the rigid and inelastic morbid structures to the cardiac nerves,
and especially to those derived from the great pneumogastric, — a
nerve which recent experimental researches, and especially those
of M. Brachet, as well as anatomical analogy, have shown to be,
to a certain extent, in all probability, a sentient nerve. The charac-
ter of the pain experienced in aneurism of the heart differs, as we
have seen, in different cases, but in some it was described as being
accompanied by a peculiar and distressing sense of weight ; a kind
of pain more intense, but still very similar to that often complained
of in aneurism of the thoracic aorta.
"The diagnosis of aneurism of the heart must, in the present
state of our knowledge, necessarily remain very doubtful. Indeed,
it is not to be expected that a diagnosis will ever be affected, without
the aid of the information to be derived from an acoustic and
manual examination. Unfortunately, the cases in which the physi-
cal signs have been observed are very few in number. In three
cases, the impulse of the left ventricle is stated to have been in-
creased ; in one, the action of the heart generally was forcible and
tumultuous; and in two others, feeble and obscure. In four cases,
a bellows or rasping sound was heard with the ventricular systole;
and in a fifth case, a similar sound was heard to the left of the
sternum. In one case, the character of the first sound was short,
like that of the second."
Such is the substance of Mr. Thurnam's account of real aneu-
rism of the left ventricle. The signs, as he admits, are wholly in-
320 HOPE ON DISEASES OF THE HEART.
sufficient to render the affection distinguishable from ordinary
disease of the heart. The physical signs, in particular, are too im-
perfectly noticed to indicate anything. So long, indeed, as particu-
lar valvular diagnosis was impossible, it was not to be expected
that murmurs could indicate anything more than some valvular
affection. But now, when particular valvular diagnosis is practi-
cable, it remains to be seen whether a new series of accurate obser-
vations will not, by excluding valvular disease, leave distinctive
signs of real aneurism. The mode of procedure would be this.
If a given murmur was not amenable to the rules explained under
the physical signs of valvular disease, nor to those of the attri-
tion-murmurs of pericarditis, (p. 127,) it might be presumed to in-
dicate something anomalous or new. The presumption would be
strengthened if the pulse was also irreconcilable with the rules
applicable to the individual valvular diseases (See Pulse of Valvu-
lar Dis.). Accurate notes should also be taken of any anomaly in
the nature, situation, and synchronism of the impulse, and in the
situation and extent of dulness on percussion, not referable to
ordinary enlargement of the heart, or to fluid within the pericar-
dium; for a small proportion of real aneurisms form tumours
exterior to the heart of such magnitude, as possibly to be capable
of producing the anomalies in question. Finally, the heart should
be examined after death, and a code of distinctive rules should thus
gradually be worked out. It was by a procedure of this kind that
I came to the conclusion, in the case of Mitchell, that there was
something extraordinary or new. The event proved the existence
of an aneurism bursting out of the aorta into the right, ventricle;
and I have drawn out rules, which will probably distinguish this
affection for the future. To offer another exemplification— I could
suppose that, in the case delineated in Fig. 20, if the physical signs
had been noticed, the murmur of aortic regurgitation, instead of
gradually diminishing down the ventricle, would have been as loud
or louder in the middle and lower parts of the cavity, because the
aneurism opened in that situation : while, at the same time, I should
have felt assured that the murmur did not result from mitral con-
traction, for two reasons: first, that there was the jerking pulse of
aortic regurgitation ; and secondly, that there was not the small,
weak, irregular, intermittent, and unequal pulse of mitral contrac-
tion, nor a murmur with the first sound indicating mitral regurgi-
tation. Under such circumstances, then, something peculiar might
have been inferred, and a real aneurism might have been assigned
as one of the presumptive causes of the anomaly.
On the whole, I am not very sanguine respecting the possibility
of detecting many of the partial aneurisms ; as a large proportion
are so small, and so situated, as probably not to create any sicrns
whatever; and many others, implicating the valves, would probably
occasion nothing more than the ordinary signs of valvular disease.
We now proceed to Mr. Thurnam's account of true aneurisms of
the auricles.
SOFTENING OF THE HEART. 321
" Aneurism of the Auricles. — The number of cases of aneurismal
dilatation which are recorded as having occurred in the left auricle,
is much less than that which we have seen to be the case in the
ventricle. The disease would appear to have been nearly uniformly
of the diffused kind, and to have generally involved the entire sinus
of the auricle."
"In one case only with which I am acquainted, was the aneu-
rism of that circumscribed kind to which the term lateral or sac-
culated could be applied. In this case there was a sac as big as a
nut hanging over the base of the left ventricle, and containing
dense fibrinous concretions and liquid blood, which communicated
with the cavity of the auricle by a canaliculated pedicle an inch in
length."
"In all the cases with which I am acquainted, whether occur-
ring in the sinus or appendage of the auricle, and which are nine
in number, the disease was connected with, and appears to have
been dependent upon, an extreme contraction of the mitral orifice,
producing a difficult transmission of the blood from the left auricle."
[" Aneurism of the Valves of the Heart. — The mitral valves have some-
times been observed to form an elongated pouch-like projection into the left
auricle, of which an example has been recorded by Morand, another by
Laennec, and a third by Mr. South. The aortic valves were found simulta-
neously extensively ossified, so that the development of the disease was
probably intimately connected with impediment to the escape of the blood
from the ventricle, and consequently greater reaction against the yielding,
and, in most instances, diseased structure, of the dilated valve. A similar
appearance has been met with in the aortic valves themselves, and even in the
tricuspid. Coagula have not been observed in the pouches so formed ; and
for their absence, the incessant agitation to which these parts are exposed,
sufficiently accounts. Such aneurismal tumours must materially obstruct
the passage of the blood by their bulk, and where the sac becomes eventually
perforated by ulceration or rupture, regurgitation will necessarily take place.
Their stethoscopic signs, we apprehend, will be merely those of obstruc-
tion or regurgitation. " — Tweedie's Library of Practical Medicine. — P.]
CHAPTER IV.
SOFTENING OF THE HEART.
Softening of the heart presents the following anatomical charac-
ters. The organ, when placed on a table, does not maintain its
round form, but sinks and becomes flattened. When the ventricles
are opened by an incision, they collapse, even though thickened.
The muscular substance feels flaccid, and tears with great facility.
Sometimes it is so soft and friable, as easily to break up under slight
pressure of the fingers. These characters are common to all the
varieties of softening.
Before noticing the varieties, it may be premised that M. Laennec
and MM. Bertin and Bouiliaud differ in their opinions as to the
11— b 21 hope
322 HOPE ON DISEASES OF THE HEART.
nature and cause of softening. Laennec supposes it to be " an af-
fection sui generis, resulting from a derangement of nutrition, by
which the solid elements of the tissue diminish in proportion as
the liquid or demi-liquid elements augment. All the muscles soften
in a moderate degree in a great number of diseases, acute and
chronic: a few days suffice to produce this effect .... and the
change takes place without any sign of inflammation." M. Bouil-
laud, (who. in his conjoint work with M. Bertin, was the sole author
of all the doctrines relative to inflammation — a fact which M.
Laennec states (Traite, ii. p. 538, note,) to have been personally
communicated to him by M. Bertin,) contends that softening, in all
its varieties of colour, is a result of inflammation ; because, as
"softening of the brain, the uterus, the kidneys, the spleen, &c. is,
in the present day, regarded as a certain characteristic of inflam-
mation," he could not adopt another opinion without doing violence
to the laws of analogy.
According to my observation, both of these conflicting opinions
are partly correct, and partly erroneous from being too limited.1
The reasons for this view will become apparent as we proceed.
Softening is almost invariably accompanied with some change of
colour, and Laennec has noticed three varieties: 1st. red; 2d. yel-
low ; 3d. whitish. MM. Bertin and Bouillaud, and more recently
M. Bouillaud, appear to have recognised the same. As the arrange-
ment by colour is convenient, I shall continue, as in the original
edition, to follow it.
According to my observation, each of the varieties may be in-
flammatory or not. When inflammatory, the red corresponds with
the first stage of carditis, and is analogous to the inflammatory en-
gorgement constituting the first degree of peripneu mony ; the tvhitish
corresponds with a more advanced stage, analogous to the second
and third degrees of peripneumony, when a pale tint is produced
by the absorption of the red particles of the blood, and by the
presence of lymph and pus in variable proportions. The yellow
variety is more, I think, a result of chronic inflammation. 1 shall
now proceed to describe each of these varieties, and shall point out,
in passing, the circumstances under which each may exist inde-
pendent of inflammation. •
1 I find that M. Bouillaud, in his more recent work in 1835, has modified
his previous opinion, and espoused that maintained in the text. "We must
not be astonished," says he, " at the confusion which reigns in what M.
Laennec has said on the subject, because, under the generic term of soften-
ing, he has confounded different morbid states. This confusion has pro-
ceeded to the extent of assigning the same name to mere flaccidity of tissues,
(mollesse,) and to softening (ramollissement) such as I here describe it
(viz. from carditis) ; it must not be concluded that, because I have con-
sidered carditis capable of producing softening of the heart, I regarded
every species of softness or softening as a result of inflammation. (Traite,
ii. 294 ; note). Again he says, (p. 296, note,) " It is possible that the soften-
ing in question, (viz. the yellow) is met with in a slight degree in subjects
who had not preseuted any symptoms whatever of obscure and chronic
carditis : such are certain cachectic individuals. This is an important ques-
tion to examine."
SOFTENING OF THE HEART RED. 323
1. Red Softening. — This variety presents a claret, morone, or
violet colour, denoting an excess of blood in the muscular sub-
stance, and I have occasionally seen it speckled, as if with extrava-
sated blood. That softening with increased redness may result
from acute inflammation, rests on incontestable evidence; for it was
found by Dr. Latham to exist in a remarkable case in which, says
he, "the whole heart was deeply tinged with dark-coloured blood,
and its substance softened; and here and there, upon the section of
both ventricles, innumerable small points of pus oozed from among
the muscular fibres. This was the result of a most rapid and acute
inflammation, in which death took place after an illness of only two
days/' The phenomenon of pus infiltrated throughout the whole
muscular substance of the heart had never been known to have oc-
curred when Laennec wrote, as appears from the admission of that
author himself; and it nullifies one of the strongest arguments by
which he supports his view that softening is not inflammatory :
namely, " I think," says he, " we may regard it as a general law in
the economy that all the soft tissues harden by the effect of a true
inflammation, that is to say, tending to the formation of pus" — this
being the only definition of inflammation that he admits (De l'Ans-
cult. ii. p. 541). Now, it is proved by Dr. Latham's case just cited,
that inflammation, taking his own definition of it — namely, "in-
flammation tending to the formation of pus," and actually forming
pus, is capable of producing softening, with increased redness: we
may, therefore, without transgressing the laws of philosophic cau-
tion, presume that it may produce the same effect, though not at-
tended with the formation of pus; for every inflammation does not
necessarily end in suppuration. This view is countenanced by the
circumstances under which, according to the concurrent testimony
of all parties, the species of softening in question is very frequently
found ; namely, accompanying acute pericarditis or endocarditis.
I have delineated two well-marked specimens of this in my work
on Morbid Anatomy, figs. 56 and 64, in neither of which was there
any pus. Red softening from inflammation, in the instances in
which I have witnessed it, has been attended with a higher degree
of tenderness and lacerability than when not inflammatory.
It remains to be shown under what circumstances red softening
is not inflammatory. I have frequently found it where there was
a retardation of the venous circulation through the muscular sub-
stance; as in dilatation with attenuation, great obstruction of the
mitral, and occasionally of the tricuspid valve, &c. Under these
circumstances, however, yellow softening is also common. Again,
red softening may result from a diseased, incoagulable state of the
blood, as in scurvy, typhus fever, &c. M. Bouillaud, in his con-
joint work with M. Bertin, aarribed the redness in typhus fever to
inflammation.1 Laennec, with better reason, refers it to the altera-
1 In his later work, he still maintains that this may sometimes be the case,
but he also admits softening from "putrid decomposition" (Traite, ii. 302;
note (2) ).
21*
324 HOPS ON DISEASES OF THE HEART.
tion or putrescence of the liquids, having always, as he states, found
it greater in proportion as the alteration was more decided. This
accords with my own observation. M. Louis also has found the
same in typhus, especially when death took place rapidly, the pulse
having been feeble, fluttering, irregular and hurried.1
Laennec inquires whether softening "could be the cause of the
extraordinary frequency of the pulse which often supervenes during
convalescence from fevers, and which sometimes persists for several
weeks, though the patient regaiu strength and substance." Bouil-
laud resolves this question in the affirmative, but adds that the
quickness of the heart's action can only be accounted for on the
view that the softening is a genuine carditis. In his later work in
1835 he thinks that mere inflammation of the internal membrane is
sufficient to produce the quickness of pulse in question (Traite, ii.
303). I do not see the necessity of resorting either to carditis or
to endocarditis to account for the quick pulse. Softening indepen-
dent of inflammation is sufficient to explain it, but there is another
cause which may contribute to its production, or which may even
alone produce it : I allude to the poor and attenuated state of the
blood usually following typhus fever — the state, in short, of anaemia,
which is amply sufficient to maintain the pulse at 100 to 120 per
minute, until the gradual restoration of the colour of the patient
evinces that the blood has regained its natural consistence and
quantity.
2. Whitish Softening. — This variety appears to have been only
glanced at by Laennec. "It ordinarily accompanies pericarditis,
says he, and is not observed in any other case .... it is accom-
panied with whitish paleness of the substance of the heart ... it
never proceeds to such a point as to produce friability of that sub-
stance : and often, the degree of consistence does not even appear to
be sensibly diminished, although the organ have become flabby,
and its walls completely sink after an incision" (De PAuscult. ii.
535). M. Bouillaud thinks that this description applies to an iden-
tical affection more fully described by Corvisart in the following
words, relating to a case in which pericarditis with effusion accom-
panied white softening of the heart : " Carditis ultimately converts
the muscular part of the heart into a soft and pale substance ; the
fleshy fibres then retain little tenacity; the cellular tissue which
unites them appears lax, sometimes it is charged (penetre) with
matter consisting of lymph and pus (lymphatico-puriilente) ; in
certain cases, it is in part destroyed ; the vascular system is more
apparent, more developed, than in the natural state, and appears to
participate in the inflammation of the other tissues. The walls of
the heart tear with the least effort, and strong pressure is not neces-
sary to reduce them to pulp" (Corvisart, p. 257-).
' Red softening from putrefaction subsequent to death must be carefully-
distinguished from real softening; and this may be accomplished by attend-
ing to the well known rule of not postponing the autopsy longer than twenty-
four hours after death, especially in warm, damp weather. Even twenty-four
hours are too long in cases of diseased blood, as typhus, scurvy, purpura, &c.
SOFTENING OF THE HEART — YELLOW. 325
This description, if correct, evidently applies to an advanced
stage of acute carditis with effusion of lymph and pus, a state
analogous, as already remarked, to the 2d and 3d stages of peri-
pneumony. I have never seen an instance of the affection: nor
does M. Bouillaud, so far as I can discover, directly state that he
has been more fortunate : whence I conclude that the inflammatory
whitish softening is rare, a circumstance which may perhaps be
accounted for by supposing that the patient either dies or recovers
before the inflammation attains so advanced a degree.
I have frequently met with a very pale and flabby condition of
the heart in cases of great anaemia, especially with atrophy of the
organ.
3. Yellow Softening. — This variety, which is much more com-
mon than either the red or the white, presents a faint yellow or
fawn-coloured tint, aptly compared byLaennec to that of the palest
dead leaves, and it bespeaks a deficiency of blood. It may pervade
the whole, or portions only of the heart, and may co-exist with hy-
pertrophy, dilatation, or other lesions of the muscular substance.
I entertain no doubt that the yellow softening may, in some cases,
result from inflammation, as I have seen it penetrate only a certain
depth, for instance, two or three lines, into the muscular substance,
as if propagated from the inflamed pericardium, which had either
become adherent, or contained false membrane and fluid.1 I have
also seen the same yellowness penetrate a line or two from the in-
ternal membrane, which presented vestiges of endocarditis. I have
likewise seen it pervade the whole thickness of the walls in patients
who, at no very remote period, had laboured under pericarditis.
But though yellow softening may be inflammatory, I fully be-
lieve, with Laennec, that it may occur independent of inflammation
in subjects who have long been in a cachectic state, or who have
been worn down by slow anaemic marcor or hectic fever. For I
have repeatedly met with instances of enlarged heart, in which the
oro-an was universally pale, flaccid and somewhat Iacerable, yet no
inflammation or fever had antecedently existed to account for the
state. The affection therefore appears to have been referable to the
same causes as, in such cases, sometimes render the other muscles
pale, flaccid and withered. Laennec remarks that those who are
affected with this chronic yellow softening, " have a pale, sallow
complexion, and a withered skin; and even when they are attacked
with dilatation or hypertrophy, as almost always happens, they do
not present any tumefaction and lividity of the face. Their lips
are rarely violet and still more seldom bloated ; on the contrary,
they are almost always nearly colourless" (De l'Auscult. ii. 536).
This statement is, for the most part, correct ; for, in fact, such pa-
tients are generally anaemic : yet, in the case of individuals with
naturally florid complexions, especially if of plethoric habit, the
1 A specimen of this is delineated in figure 61 of the writer's Morbid
Anatomy.
326 HOPE ON DISEASES OB1 THE HEART.
presence of anaemia does not prevent the cheeks, nose, and lips from
becoming purple or livid, and the face and lips more or less bloated:
the patients, in short, are amenable, though in a less degree, to the
same general rules with respect to colour, as are explained at p. 266,
in reference to hypertrophy.
As softening diminishes the cohesion, and therefore the elasticity
of the heart, we are necessarily led to infer that it conduces to dila-
tation : accordingly we find that dilatation is its almost constant
concomitant, when it has subsisted for a considerable period.
Signs and Diagnosis of Softening.
General Signs. — As softening from acute inflammation is al-
most— perhaps wholly, unknown except as a concomitant of peri-
carditis or endocarditis, there is difficulty in distinguishing its signs
from those of the other maladies. Complicated with them, it is at-
tended by a quick, feeble, small, and faltering pulse, great anxiety,
and a disposition to syncope — the same symptoms, in short, that
characterise pericarditis with copious fluid effusion, and endocardi-
tis with polypus choking the cavities. Now, as copious effusion or
polypus is often present when the inflammation is so severe as to
affect both the membranes and the muscular substance, it is scarcely
possible, in every case, to say positively whether the severe symp-
toms in question depend on the effusion and polypi, or on the soft-
ening. I feel assured, however, that the latter, as well as the for-
mer, is capable of producing them ; as they sometimes exist when
there is neither polypus, nor a quantity of fluid sufficient to consti-
tute an adequate cause, and as it is consistent with analogy to sup-
pose that the muscular tissue of the heart, when softened by
inflammation, would, like other muscles, be rendered incapable of
adequately discharging its function. In this point of view, soften-
ing greatly aggravates the severity and danger of endocarditis and
pericarditis.
The general symptoms of softening from chronic inflammation
or other wasting disease, as scurvy, hectic, anaemia, typhus fever,
&c, are no less ambiguous ; as they may result from the primary
disease itself, independent of softening. They are, general lan-
guor; a sallow, exsanguine, withered complexion ; with a purple
or livid tint of the cheeks and lips in the naturally florid ; a quick,
but soft and feeble beat of the heart and pulse, often with great in-
termittence, irregularity and inequality ; gradual reduction of the
strength; and dropsical effusion, sometimes amounting to general
anasarca, from inability of the heart to propel its contents.
I have frequently found softening after a series of symptoms men-
tioned by Laennec : namely, when, in a case of dilatation with or
without hypertrophy, there have been long and frequent attacks of
suffocative dyspnoea ; when the struggle between life and death has
been protracted, — of several weeks' duration, for instance ; and when
the violet hue of the face, the extremities and the other parts of the
surface of the body, had announced, long before death, the retarda-
SOFTENING OF THE HEART DIAGNOSIS. 327
tion of the blood in the capillary system. The three cases appended
to the present chapter were of this description. 1 have invariably
found such cases attended, after death, with great pulmonary en-
gorgement, and often with the "pulmonary apoplexy" of Laennec.
Passive haemoptysis of dark, grumous blood frequently exists during
the last days of life.
Physical Signs. — As the systole and diastole of the heart are
enfeebled by softening, its impulse is more or less reduced in
strength ; and it frequently happens that the beats are not only in-
termittent and irregular, but very unequal in force, an occasional
beat being pretty strong, while the others are very feeble, or even
imperceptible. Whenlhese occasional beats are decidedly stronger
than natural, I always venture to found on them a diagnosis of hy-
pertrophy. Both the sounds are rendered weaker than natural by
softening, and the first sound becomes short and flapping like the
second, in consequence, I presume, of its being produced solely by
extension of the auricular valves, the ventricular systole being too
feeble to generate muscular sound. This flapping character of the
first sound, even though hypertrophy accompany the softening, has
not hitherto been noticed by authors as characteristic of the latter
affection.
Diagnosis. — In the former editions of this work, 1 experienced
a difficulty in detecting softening when complicated with hypertro-
phy, because it could not be affirmed that the diminution of the
first sound was not referable to the hypertrophy rather than to the
softening ; but this difficulty is now removed by the first sound in
hypertrophous softening being of the short, flapping character above
noticed, while there still remain the ordinary physical signs of hy-
pertrophy— the augmented impulse, either constantly or with oc-
casional beats, and the increased extent of dulness on percussion.
The irregularity of the pulse presently to be noticed, isan additional
indication of softening, because this sign is foreign to mere hyper-
trophy.
The diagnosis of softening from disease of the valves, especially
of the mitral, producing an irregular pulse, requires particular no-
tice. When the first edition of this work was published, I was not
sure that softening had any particular effect on the regularity of the
heart's action : but I have subsequently ascertained that, when con-
siderable, and especially if conjoined with dilatation or oven hyper-
trophy with dilatation, it produces an eminently small, weak, inter-
mittent, irregular and unequal pulse, such as is occasioned by the
highest degrees of disease of the mitral valve. Three cases, selected
from several others, are appended to the present chapter, expressly
for the purpose of exemplifying this fact, which has hitherto been
overlooked by authors.
But though the pulse of softening be the same as that of disease
of the mitral valve, there is little difficulty in the diagnosis of the
two affections. If after an exploration made according to the rules
offered at p. 114, no murmur be found to attend either sound of the
328 HOPE ON DISEASES OF THE HEART.
heart, the irregularity of the pulse must be ascribed to softening,
provided it be not referable to temporary nervousness, to a paroxysm
of dyspnoea, or to ebbing of the vital powers on the approach of
dissolution — all of which circumstances are capable of producing
transitory weakness and irregularity of the pulse, even in a healthy
heart.
[" The softened and somewhat glutinous state of the heart, observed in
the advanced stage of putrid fevers, was supposed by Laennec to be but a
part of the general affection of the muscular system in these cases, owing to
a diminution of their solid, in proportion to their liquid constituents. Dr.
Stokes, who has recently paid much attention to this subject, takes rather a
different view of it, considering the softening of the heart to be a peculiar
local secondary effort of typhus, and often to exist where the muscles of lo-
comotion are little, if at all, altered from their natural colour and consistence.
{Dub. Med. Journ., March 1839.) When it exists in a marked degree, the
first sound of the heart becomes quite inaudible and the impulse deficient.
From the great feebleness or absence of the systolic sound, he has satisfied
himself that a valuable practical indication may be deduced in respect to the
propriety of resorting to stimulants, and one which he holds to be much
more trustworthy than the state of the pulse, which is not always, by any
means, in accurate relation with it. Accordingly, where there is absence or
extreme diminution of the first sound in typhoid fevers, he administers wine
boldly, no matter what other secondary affections of the gastro-intestinal
mucous membrane, pulmonary organs or brain, may co-exist, and believes
that where the stimulant plan is, under such circumstances, neglected, and
the strength not adequately supported until this and other concomitant
secondary affections, as well as the fever itself, have run their course,
syncope is very apt to occur and prove fatal. Where, on the contrary,
wine and other stimulants having been diligently exhibited during a day or
two, the pulse begius to lose its frequency, and the first sound of the
heart becomes again audible, the prognosis becomes decidedly favourable,
and the propriety of the line of treatment adopted confirmed.
" There remains still another species of softening of the heart to be adverted
to, — viz., that where an unusual quantity of fat envelopes the organ, and is
intermixed with its muscular fibres, its substance in such cases loses alto-
gether its natural firmness, and becomes of a peculiarly light colour, and
seems prone to rupture.
"It is probable that many obscure cases of sudden and unexpected death
have their origin in syncope connected with ramollissementof the heart. The
treatment of softening of the heart when independent of inflammation, or
where this, ifits original cause, has been subdued, is similar to that of dila-
tation, a morbid condition with which, as we have seen, it very frequently
co-exists." — Dr. Joy, Tweedie's Library. — P.]
Prognosis. — The prognosis of softening depends much upon the
co-existent and, as it were, primitive affection. As above stated, it
greatly augments the danger of pericarditis, and probably of fever ;
but when these affections terminate favourably, there is every rea-
son to believe that the muscular substance may be restored to its
healthy condition. With chronic maladies, and especially organic
disease of the heart, softening is an aggravant of the worst kind;
for it not only contributes powerfully to weaken the heart, but, by
'impairing the tone and elasticity of the muscular fibre, it has ap-
peared to me to counteract that natural tendency of the heart tore-
cover itself from dilatation, and dilatation with hypertrophy, which
SOFTENING OF THE HEART — CASES. 329
has been shown (p. 284) to exist in a high degree under favourable
circumstances of treatment. Hence, of all cases of dilatation, those
attended with softening are, caeteris paribus, the most difficult to
cure.
Treatment. — When accompanied by acute inflammation, soften-
ing must be treated on the same principles as pericarditis. When
a result of chronic disease, it demands the same remedies as the
primary affection, and especially iron, bark, a nutritious animal
diet, and good air, if they be not otherwise contraindicated. Iron
in full doses is particularly required, and is eminently useful, in
anaemic subjects. These remedies must be superadded to perfect
tranquillity of body and mind, and the other means calculated to
prevent palpitation and engorgement of the organ, as already ex-
plained at p. 310, under the head of Dilatation. Complete cessa-
tion of palpitation is not to be expected till anaemia is removed, for
this alone is capable of maintaining the symptom. Nor is a diminu-
tion of co-existent dilatation to be looked for till a restoration of the
tone of the general muscular system and a decrease of the physical
signs of softening, denote that the heart has recovered somewhat of its
natural tone and elasticity. If the treatment should commence at an
advanced period of the disease when dropsy has set in, the diuretics
employed should have a tonic basis, as cascarilla, qnina and gentian ;
the strength should be carefully supported by as much animal nu-
triment as the stomach will bear; and diffusible stimulants — even
wine and brandy, should be administered, if there be a decided
failure of the circulation, with tendency to sinking, especially in
the last stage of softening.
The three following cases illustrate softening.
Dilatation; softening: irregular pulse. No valvular disease.
Case 1. — A. B., a man in St. George's Hospital, under Dr.
Chambers, Aug. 12, 1835. Had been nearly drowned eight months
previous to admission. Symptoms of disease of the heart ensued.
I found very extensive dulness on percussion. Impulse slight,
and very irregular ; Pulse extremely irregular, unequal and inter-
mittent, so that there was the greatest difficulty in ascertaining its
coincidence with the ventricular systole, which was frequently
unattended with pulse. Sounds, both very weak, and the first of a
short, clicking character. No murmur. Was subject to agonising
dyspnoea, and died during a paroxysm of three days duration.
Diagnosis. Dilatation : no disease of the valves.
Autopsy (at which I was not present). — Heart greatly enlarged
by dilatation, with about the natural thickness of the walls, but
they were very soft and flabby. No disease of the valves.
Remarks. — This was one of the first cases which gave me
strong assurance of what I had long suspected : viz. that softening
was productive of irregularity of the heart's action. The following
remarks are appended to the case in my note-book. " The soften-
ing appears to have been the cause of the extieme irregularity of
330 HOPE ON DISEASES OF THE HEART.
the heart's action, as, when the muscular substance is firm, an
equal degree of dilatation may be unattended with irregular pulse,
except during paroxysms of dyspnoea, or failure of the vital powers.
May not this irregularity, therefore, be added to the signs of soften-
ing when there is no disease of the valves, indicated by murmur,
to account for the irregular pulse ?"
On these grounds, I gave a diagnosis of softening in the two
following, amongst other cases. In all the cases, the patients died
after a difficult and protracted struggle, as described by Laennec.
Softening ; Dilatation ; no valvular obstruction ; pulse extremely
irregular ', fyc. ; pulmonary apoplexy.
Case 2. — Mr. Wm. Saunders, aet. 40, fat and plethoric. I at-
tended him with Mr. Farquhar, surgeon, in January 1838. Ill a
year. Now, purple and livid lips and cheeks ; sallow between ;
bloated ; great dyspnoea, but no orthopnoea; considerable anasarca;
no hydrothorax. Impulse not perceptible. First sound as short
and flapping as the second, and there are two or three sounds for
every distinct beat of the pulse, the other beats being either very
feeble or wholly imperceptible. Second sound, above the sigmoid
valves, distinct but feeble. Duiness on percussion. Died in three
weeks, without haemoptysis.
Diagnosis. — Dilatation; softening; no valvular contraction or
regurgitation ; no hydrothorax.
Autopsy. — Very extensive pulmonary apoplexy in both lungs,
which were, in consequence, much diminished in volume. No
hydrothorax. Heart enlarged to double. Walls of left ventricle
half an inch thick, and rather flabby and pale (softening); its cavity
enlarged to double. Walls of right ventricle a quarter of an inch
thick : cavity large. Aortic valves very slightly thickened, but
not contracted: capable of discharging their function. Mitral valve
also thick and opake, and chordae tendineae rather thick, but the
valve admitted three fingers easily, and seemed capable of closing
the orifice. Tricuspid and pulmonic valves rather thickened, but
not contracted.
Remarks. — We here again see that a most intermittent, irregu-
lar, unequal, small, and weak pulse, with extreme venous retarda-
tion— symptoms usually supposed to be dependent on valvular
disease, resulted from softening with dilatation alone. I inferred
the softening from the state of the pulse being unattended with
valvular murmurs, and from the weakness of the sounds. The
dilatation was indicated by the flapping character of the first sound,
the duiness on percussion, and the absence of impulse.
Extreme softening ; great hypertrophy with dilatation ; no val-
vular disease ; pulse extremely irregular ; fyc. ; pulmonary
apoplexy.
Case 3. — Sir , Bart., whom I attended with Dr. Chambers,
ast. 69, fat, fifteen stone. Had been affected for six or seven years
SOFTENING OF THE HEART — CASES. 331
with an intermittent pulse, and slight hurry of the respiration on
exertion : three years before death, he had severe jaundice, and
subsequently had slight ailments, which were ascribed to derange-
ment of the stomach and liver. A fatty state of the heart being at
length suspected, immoderate exercise was injudiciously taken, with
the view of reducing it. He was attacked with constant palpitation,
most oppressive dyspnoea, and complete sleeplessness. As these
symptoms did not abate in a week, he travelled 100 miles up to
London in one day, and on his arrival I saw him for the first tirne.
His complexion was very sallow, with purplish cheeks, nose and
lips; oppressive dyspnoea, but not orthopnoea; pulse extremely
intermittent, irregular and unequal, an occasional beat being
stronger and larger than natural, while the intermediate beats
were very small, weak, and often imperceptible. Slight oedema
pedum.
Auscultation. — Impulse, a flutter with an occasional bound of
inordinate force. Sounds, both weaker than natural, and the first
as short and flapping as the second. No murmurs. Contractions
of the heart were 130 to 140 per minute, and the pulse 40 to 60.
Percussion, prevented by a vesication on the precordial region.
The symptoms increased. Whenever drowsiness slackened
voluntary respiration, gasping came on and aroused him, and this
occurred alternately every four or five minutes. Next supervened
expectoration of dark blood, failure of the pulse, and moderate ana-
sarca: finally, diminution of sensibility, and death in a fortnight,
after a protracted struggle.
Diagnosis. — Hypertrophy with dilatation, which I inferred from
the occasional strong impulse, and strong, large pulse. No valvular
contraction or regurgitation, because no murmur, and because
great mitral contraction or regurgitation was incompatible with the
occasional strong beats of the pulse, which is always weak in such
mitral disease. Softening, because, without mitral disease, the pulse
was irregular, &c, and because there was passive haemoptysis and
great, venous retardation ; also because the sounds were weak and
the first short, though there was hypertrophy with dilatation. Pul-
monary apoplexy. No hydrothorax.
Autopsy. — Cavities of the pleura contained two ounces of bloody
serum. Lungs, universally gorged and black : whole inferior lobe
of the left, in the state of pulmonary apoplexy. Heart, dilated to
the size of a bullock's, being nearly three times as large as the
closed fist of the subject. Walls of left ventricle thickened to about
three quarters of an inch : muscular substance dark red from
sano-uineous endorsement, and so much softened that a finger and
thumb passed through it with very little pressure. All the valves
perfectly healthy and capable of discharging their functions, except
that the mitral and aortic were strong and rather opake, from
hypertrophy of the fibrous tissue. Walls of the right ventricle of
natural thickness, but the external third of the muscular substance
was replaced, over a considerable extent, by fat, Auricles dilated
to double.
332 HOPE ON DISEASES OF THE HEART.
Remarks. — This case presents the general signs usually ascribed
to great valvular disease, and I adduce it, both to evince that soften-
ing alone may occasion these signs, and to furnish data for the
diagnosis. Pulmonary apoplexy has not, I believe, been noticed as
a consequence of softening. I have met with it in several other
cases, as well as the present. It is produced on the same principle
as when it results from great disease of the mitral valve: viz. a
powerful obstacle to the transmission of blood out of the lungs
through the left side of the heart, the obstacle here consisting in
the weakness of the organ and its consequent inability to propel its
contents.
CHAPTER V.
INDURATION OF THE HEART.
The muscular substance of the heart sometimes undergoes in-
duration. Corvisart has found it carried to such an extent that
the heart, when struck, sounded like a dice-box or hollow horn
vessel, and the scalpel, on making an incision, experienced great
resistance, and produced a singular crepitating noise. Yet the
fleshy substance possessed its proper colour, and did not appear
converted into either an osseous, a cartilaginous, or any similar
substance. This affection is very rare. Laennec and Bertin have
met with it affording a resistance to the scalpel, but not causing
the crepitating noise ; and the same has occurred to myself. It
generally occupies the whole of a ventricle, but sometimes only a
portion ; and it may accompany any state of the organ as to size,
though most commonly it is conjoined with hypertrophy.
It consists, I apprehend, not merely, as Laennec supposed, in an
increase, but in a perversion of nutrition, being somewhat different
from that firmness which the heart frequently acquires by hyper-
trophy. MM. Bertin and Bouillaud, with I think the majority of
authors, regard it as one of the products of chronic inflammation.
[Bertin and Bouillaud regard this induration as a preparatory step to ossifi-
cation ! Laennec's views differ from this, for the reason that induration of
the heart, when it exists, generally affects the entire organ, and has its
principal seat apparently in the muscular tissue; whilst ossification is com-
monly partial and has its chief seat in the serous, cellular and fibrous tis-
sues.— P.]
Induration, according to Laennec, increases the impulse of the
heart. The firmest hearts with which he had met, were also those
which gave the strongest impulse. But it is conceivable that when
the induration proceeds beyond a certain point, it must, as Corvisart
thought, render the contraction of the ventricles more difficult, and
their movements more limited.
The treatment of induration with increased action of the heart
is identical with that of hypertrophy.
ADIPOSE AND GREASY DEGENERATIONS. 333
CHAPTER VI.
ADIPOSE AND GREASY DEGENERATIONS OF THE HEART.
Excess of Fat. — In individuals remarkable for obesity, and occa-
sionally in others of only moderate embonpoint, the heart is some-
times greatly overloaded with fat, which, deposited between the
pericardium and the muscular substance, not only covers the
organ externally, but frequently penetrates a considerable depth
between its fibres; whilst the walls themselves, as if losing (pro-
bably by the pressure) what the adipose tissue gains, become
attenuated and flabby.
The older authors imagined that this affection was the cause of
more or less severe symptoms, and even of sudden death. Cor-
visart thinks that an enormous accumulation might sometimes
produce such an effect, though, in the persons in whom he had
met with very fat hearts, he had seen nothing which could prove
to him " that the state was morbid, that is to say, carried to such a
point as constantly to derange the function of the organ, and thus
constitute a malady." The experience of Laennec has led him to
the same conclusions.
Appended to the present article are three cases, which lead me
to suspect that fat does impede the action of the heart and obstruct
the circulation ; and that its signs, so far as I can yet judge, are,
1, diminution of the sounds — especially the first; 2, irregular pulse,
without valvular disease; 3, "oppression" or even pain in the
precordial region, with general signs of a retarded circulation,
producing cerebral, hepatic, and other congestions. These signs,
taken in conjunction, are peculiar; because, while No. J is proper
to simple hypertrophy, Nos. 2 and 3 are foreign to its early stages:
the aggregate therefore probably denotes an encumbrance of the
organ with fat, as will appear from the subjoined cases.
It would be natural to suppose, that the substitution of adipose
for muscular tissue, and the extreme attenuation which the walls,
especially the apex and the posterior part of the right ventricle,
sometimes undergo from this cause, would be eminently favourable
to rupture of the organ ; yet this accident is very rarely the result.
Morgagni has seen it, but Bertin has only met with a case of rup-
ture of the auricle, while Corvisart and Laennec have not met
with an instance at all. The alteration described is different from
that denominated —
[" The heart is often found overloaded with fat, especially about its base,
and along the course of the coronaries, in the furrow of separation between
the adjacent cavities, and likewise occasionally on its flat surface. In such
cases, there is often an excess of the same substance in the neighbouring
mediastinum, especially in front of the pericardium. The muscular structure
of the heart is ordinarily much reduced in thickness and firmness, where in
contact with the accumulated fatty deposite, either in consequence of its
pressure, or from the new appropriation of the nutritive fluid.
334 HOPE ON DISEASES OF THE HEART.
" The heart in one or more of its cavities is in these cases frequently at
the same time greatly enlarged. Though the adipose matter may occa-
sionally penetrate for some way between the muscular fibres, yet the two
structures do not here run insensibly into each other, but are, on the con-
trary, perfectly distinct, so as to be capable of being separated cleanly by
the dissecting knife. Corvisart, Laennec, and Hope, all agree in considering
this as a mere augmentation of a natural deposite, and unattended, as far as
their experience reaches, with any definite morbid symptoms: still if in
very great excess, it could scarcely fail, we apprehend, in some degree, to
enfeeble or embarrass the heart's action. M. Chomel believes that it may,
in such extreme cases, give rise to dyspnoea, palpitations, and a sense of
sinking, together with feebleness of pulse and dropsical tendency; and
others, as we have already seen, ascribe to it, though on less plausible
grounds, the production of all the symptoms of angina pectoris. Dr. Hope
•considers its signs to consist in ' diminution of the sounds, especially the
first; irregular pulse without valvular disease; and oppression or even pain
in the precordial region; with general signs of a retarded circulation, pro-
ducing cerebral, hepatic, and other congestions.'
" It is much more common in females than in men, and is met with
frequently when there is no tendency to obesity in other parts of the body.
The habitual use of fermented liquors to excess seems in some constitutions
to favour the morbid deposition of fat in this as well as in other situations.
" But besides the condition above described, the heart is liable, like the
solsei, and some other muscles, to a species of true fatty degeneration, in
which a proportion of the muscular tissue of the organ becomes actually
transmuted iuto adipose matter. This change seems generally to com-
mence towards the apex of the organ, and thence spreads upwards; and has
appeared in some instances to be ushered in by infiammaiory symptoms.
Unlike the former species of fatty deposite; the transition here from the one
to the other tissue is gradual and insensible. The affected parts are of a
pale yellowish hue, softened and greasy to the touch. The external mus-
cular layers suffer first, and from these it spreads gradually inwards till a
mere shell of muscular substance has been left, consisting, in extreme
cases, such as that recorded by Mr. Adams, of little more than the reticu-
lated interior of the ventricle; and even those fibres which are but little
altered in appearance will impart to paper a greasy stain, as Laennec has
pointed out. The latter had never, within his own experience, known it to
determine a rupture of the heart, and confessed himself unable to ascribe to
it any characteristic symptoms. It seems obviously, however, from the
cases recorded by Mr. Adams and Dr. Cheyne, to predispose to serous
effusions and to apoplexy, as the impediment to circulation, necessarily
connected with such a weakened state of the heart, would lead us to
expect." — Dr. Joy, Op. citat. — P.]
Greasy Degeneration of the Heart. — This, according to Laen-
nec, is " an infiltration of the muscular substance with a matter
which presents all the physical and chemical properties of grease;
it is an alteration exactly similar to the greasy degeneration which
Haller and Vicq-d'Azyr have observed in the muscles. Laennec
has never found it but in a very small portion of the heart, and
only near the point. It was of a pale yellowish colour, like dead
leaves, and therefore very similar to certain varieties of softening;
but he thinks that it may be distinguished from this, by its strongly
greasing paper between which it is pressed. I have seen a remark-
able case in which a degeneration of this kind occupied the greater
part of both ventricles.
ADIPOSE AND GREASY DEGENERATIONS. 335
[" In two remarkable examples of greasy degeneration of the heart, de-
scribed by Mr. Smith of Dublin, globules of a limpid oily matter were found
floating on the blood in such quantity that half an ounce of pure oil was
easily collected, — its presence affording, as Mr. Smith remarks, an additional
evidence of imperfect assimilation. In one of these cases, too, rupture of the
left ventricle had taken place. In similar cases the texture of the heart,
which breaks down readily between the fingers, has been compared to liver
by M. Bizot.
" If this affection were recognisable during life, the appropriate treatment
would consist in such measures, dietetic and medicinal, as are calculated to
give additional activity to the processes of digestion and assimilation, to
render the circulation less languid, and to cause the absorption of redundant
adipose deposites; — such as suitable exercise in a bracing atmosphere, tem-
perance in diet, due regulations of the functions of the stomach and intes-
tines, together with the exhibition of such remedies as are known to increase
the tone of the nervous, muscular, and vascular systems. The preparations
of iodine, moreover, on account of their marked influence over the absorbents,
especially those of the cellular tissue, would seem here to be deserving of
trial."— Dr. Joy, Op. citat.—P.]
Atrophy and aidcma of the adipose tissue. The former some-
times accompanies general emaciation, and the latter presents
itself in cases of universal dropsy.
[" An ccdematous state of the cellular membrane enveloping the heart,
and connecting its fibres, has been noticed by M. Bouillaud, both in connec-
tion with a general dropsical condition of the system and also with a vari-
cose appearance of the cardiac veins, indicative of the difficulty with which
they discharge themselves into the right auricle, in consequence, generally,
of some concomitant obstruction within the heart. A similar dropsical state
of the organ may also originate in obliteration of some of these same
vessels." — Op. citat. — P.]
Two of the subjoined cases were not attended with dissections,
and the signs were therefore only presumptive. The third, pre-
senting analogous signs, was verified by dissection.
Oppression of heart ; p. irregular ; impulse increased; sounds
diminished; cerebral congestion ; presumed fatty heart.
Case 1. — P d, Esq., oet. 40, a large, robust, and rather
plethoric man. For two or three years, has been subject to occa-
sional giddiness, stupor, loss of memory, numbness of the right
arm, and difficult articulation, with palpitation, " oppression in the
heart," and pain striking to the sternum. Bowels costive; dys-
pepsia. Pulse at present intermittent, and neither full nor hard,
but contracted. Impulse of the heart considerably increased and
heaving. Sounds. 1st, inaudible when the heart beats 70; barely
audible when 90: 2d sound, feeble. No murmur.
Remarks. — I do not recollect ever to have heard the 1st sound
so suppressed, both on the right and left side, as in this case : yet
the impulse was strong and heaving ! There are only two states
which can easily account for the deficiency of sound : viz. either
hypertrophy with contraction, or a fatty state of the heart — which
had been suggested to the patient. The event must show. I can
imagine that fat, partly by encumbering the heart's action, and
336 HOPE ON DISEASES OF THE HEART.
partly by increasing the thickness of the walls through which the
sound has to be transmitted, may be capable of occasioning the
suppression of the first sound.
On the 11th of March, 1836, a week after my previous examina-
tion, he had an attack of cerebral congestion, with difficult articu-
lation, numbness and formication of the right arm, confusion of
memory, pulse irregular, &c. (V. S. Enema purg. — Haust. Piirg.
— Capiti raso lotio frigida. — Emplast. Lyttas occipiti. — R cal. gr
iij. opii gr ss, 4tis h. — Slop diet.) On the following day, the blood
was found slightly buffed; numbness of arm gone; articulation
distinct, but slow ; pupils rather sluggish ; no headache (contr. pil.
cal. c. opio). The mouth was slightly affected by the mercury,
which was diminished as the symptoms declined. At the end of
three weeks, he was perfectly well of the cerebral attack. I then
found the sound of the heart more audible, the impulse diminished,
and the pulse regular and less contracted — symptoms indicating
that the organ disgorged itself more freely.
Was ordered to avoid exercise, mental excitement, all stimulant
drinks, and to live principally on fish and fowl instead of animal
food, for at least two years.
During this period he lost fat, but gained strength; the sound
became louder, the impulse less, and the pulse larger and more re-
gular. Was this the result of absorption of fat, or of diminution of
hypertrophy with contraction? The former is more probable. I
have not seen the patient during the past year.
Angina; p. irregular ; impulse increased ; sounds diminished ;
presumed fatty heart.
Case 2. — S n, Esq., a medical practitioner, set. 40, ex-
tremely fat and florid, (17f stone,) consulted me Aug. 3, 1836. Oc-
casional slight pain in the heart, but more frequently "oppression."
Little inconvenience from moderate exercise. Digestion excellent.
Bowels regular. Pulse irregular, and some beats are fuller than in
a healthy male of average size. (Therefore, no contraction of the
left ventricle in this case.) Impulse slightly increased, but not
easily felt, from obesity. Sounds : both rather dull, especially the
first, and more, I think, than is accounted for by the external obe-
sity. No murmur. He has often been cupped and leeched, which
eased the oppression. Lives low.
Diagnosis. — Hypertrophy is indicated by the increased impulse
and the occasional large beats of the pulse. As permanent irregu-
larity of the pulse is foreign to hypertrophy in a vigorous, healthy
subject, the irregularity is probably referable to fat encumbering
the organ. The same occurred in Mr. P.'s case. Investigate the
subject. Important to discover whether fat produces these symp-
toms, because the disease may perhaps be ver'y curable by liq. po-
tassae, iodine, dry diet, &c.
(Local bleeding to § x or xii, now, and a fortnight hence : sub-
sequently, every month, till contraindicated. — Lower diet: less
ADIPOSE AND GREASY DEGENERATIONS. 337
animal food. — Liq. potass, m xx to xl ter die. — To weigh him-
self periodically.)
In six weeks he lost 11 lbs. by the application of 100 leeches,
which drew 44 ounces of blood. He had raised the doses of liq.
potass, to 3ij daily. All pain and oppression had subsided, and he
felt much relieved without being weaker. The pulse was still irregu-
lar and intermittent, but moderately full and strong : first sound,
louder — almost as distinct as natural : impulse still slightly in-
creased when a strong beat is felt.
During the ensuing six weeks, he lost 23 ounces of blood by 56
leeches; by which his weight sustained a further reduction of 2\
lbs. He omitted the liq. potass. All the symptoms continued to
improve, but the sounds were still not quite distinct enough.
During the subsequent four months, he very seldom experienced
angina; and it was always relieved by leeches and vini colch. m
xl., which acted in an hour as a free diuretic. The first sound
became as distinct as natural, and he felt active and well. The
pulse was still intermittent and irregular, but much less so than
formerly. Remark. I imagine that the walls are thinner and
less encumbered with fat, whence freer action. (Contr. omnia pro
re nata.) Up to the present time, March 1839, he has maintained
his ground.
Oppression at the heart ; p. irregular; sounds weak; hepatic
congestion ; fatty heart found.
Case 3. — Mr. P r, (whom I attended with Mr. Linnecar
Mr. Lucas, and Dr. Chambers,) set. 50 ; stout, fat, (15 or 16 stone.)
Occasionally, '; oppression^ at the heart, and pain down the inside
of the left arm. Can walk up stairs and up hill with little incon-
venience. P. very irregular and unequal, and a strong beat oc-
casionally. Flatulence ; b. regular from aperients. Impulse pretty
strong when the pulse presents a strong beat. Sounds : both very
dull. The first is, I think, but am not quite sure, attended with a
murmur over the aortic valves, with the strong beats of the pulse
oniy. Three years ago, had inflammation of the heart.
Diagnosis. — Either simple hypertrophy, or, as this does not
properly cause an irregular pulse, fattiness of the heart in addition.
(V. S. ad 3 vi, subinde. — Liq. potass. Z\ ad 3 i ter die. — Aperients;
lavements; meat and fish on alternate days. — No wine, spirits, or
malt liquors, and a dry diet. — Quiet. — To lose a stone weight.)
May 1, 1838. After three weeks of the treatment, the pulse was
fuller and less irregular ; the beat of the heart stronger ; the first
sound rather louder. Oppression of the heart and pain of arm
gone ; felt lighter and better.
In five weeks more, he was still better in all respects. Impulse
and first sound stronger; p., though intermittent, was very full and
pretty strong (hypertrophy with dilatation). No Joss of weight,
but abdomen diminished. He continued to improve up to the end
of Oct., when he was attacked with some acute affection, for which he
11 — c 22 hope
338 HOPE ON DISEASES OF THE HEART.
was treated by another physician. Six weeks later, I again attended
him in consultation. The liver was now so large as to descend be-
low the umbilicus, and he was deeply tinged with icterus. There
were the usual symptoms, in a marked form, of universal venous
retardation. By mercury and aperients the liver was brought al-
most within the margin of the ribs, but the retardation continued,
and he died, greatly emaciated, in about three weeks.
Autopsy. — -A layer of fat upwards of half an inch thick occu-
pied the anterior mediastinum, in front of the heart. The anterior
and lower half of the right ventricle was covered with a layer of
fat about a quarter of an inch thick. The heart was about one
half larger than natural. The left ventricle was three quarters of
an inch thick, and its cavity dilated. The right valves were sound.
The left were slightly thickened by fibrous hypertrophy and stea-
toma, but were of natural dimensions, and also flexible and efficient.
A few steatomatous depositions, with slight corrugation, existed at the
origin of the aorta, and occasioned the slight murmur heard in that
situation. The heart was soft and flabby. Liver, not enlarged ; of
the nutmeg appearance.
Remarks. — *4.s the corpse was emaciated, it is probable that,
during life, the accumulation of fat had been more considerable.
It is also probable that the fat had encumbered and embarrassed
the organ ; since it is not usual for such a degree of hypertrophy
with dilatation as existed in this case, to produce irregularity of
the pulse and diminution of the sounds, except in feeble, exhausted
subjects — which was not originally the case in the present instance.
The hepatic tumefaction was, I presume, occasioned by the venous
retardation ; first, because it came on suddenly ; secondly, because
it was speedily removed.
CHAPTER VII.
OSSEOUS, CARTILAGINOUS, AND OTHER ACCIDENTAL PRODUCTIONS
CONNECTED WITH THE MUSCULAR SUBSTANCE OF THE HEART,
AND WITH THE PERICARDIUM.
Osseous and cartilaginous productions penetrating into, and re-
placing the muscular substance, are very rare. They originate, not
in the muscular fibre itself, but either in the fibrous tissue of the
pericardium, or in the cellular tissue uniting it or the endocardium
to the heart, and dipping in between the fasciculi of muscular
fibres. This is in accordance with the general laws of embryogony
and of the animal scale : namely, that certain tissues only are con-
vertible into certain others; that cellular tissue is the matrix, as it
were, of all others, and that cellular may be transformed into fibrous,
fibrous into cartilaginous, and cartilaginous into osseous.
Corvisart has seen the point of the heart, in its whole thickness,
and the left columnas carneae, converted into cartilage. I have seen
the same at the base. Fig. 20 is an ossified aneurism. Burns has
seen the ventricles perfectly ossified, so as to resemble the bones of
OSESOUS AND CARTILAGINOUS PRODUCTIONS. 339
the cranium. Haller, Filling- and Bertin have seen partial osssifi-
cations. M. Renanldin has found the left ventricle converted into
a real petrifaction, which had a sandy appearance in some parts,
and in others resembled a saline crystallization. In all these cases,
the disappearance of the muscular fibre is referable to atrophy,
resulting from compression by the encroachment -of the new pro-
ductions.
Cartilaginous incrustations occasionally exist between the lining
membrane and the muscular substance. Kreysig found one in an
ossified state. Mr. Thurnam describes several cases of fibrous,
cartilaginous, and osseous disease of the muscular substance, in con-
nexion with real aneurism of the left ventricle (see p. 314).
All these transformations are generally results of pericarditis or
endocarditis.
Laennec feels persuaded that an osseous or cartilaginous indu-
ration of a large portion of the heart, as a whole ventricle or halfthe
organ, could be recognised with the cylinder, by a very marked aug-
mentation, and some particular modifications, of the sound of the
organ. He thinks that cases of this nature are amongst those in
which the sound of the heart can be heard at a certain distance from
the patient. These anticipations have not been realized ; and it is
now very apparent why they should not. For, as it has been shown
in the experiments at p. 48 et seq. that the first sound of the heart
is occasioned by the extension of the muscular walls and of the
auricular valves, it is obvious that, when the force of this extension
is diminished by the substitution of cartilage or bone for muscular
fibre, the sound must sustain a corresponding diminution of intens-
ity. Accordingly, in some of Mr. Thurnam's cases, the sound
actually was enfeebled. The only case in which I can imagine it
augmented, would be, when the apex is indurated and creates an
adventitious sound or metallic cliquetis, by impinging against the
inferior margin of the fifth rib, in the manner explained at p. 72.
It is probable that fibrous, cartilaginous, and osseous transform-
ations of the muscular substance would generally be attended with
a murmur, because they almost always implicate the valves. If the
surfaces of the pericardium were roughened by the disease, an
attrition-murmur would be the result. On this subject, as on real
aneurisms of the left ventricle, a new series of observations is re-
quired ; the physical signs, in the cases that have hitherto occurred,
having been very imperfectly explored.
Osseous and cartilaginous depositions sometimes take place in the
reflected pericardium, being originally seated either in the subserous
cellular tissue, or in the fibrous layer itself. Though they do not
properly fall amongst the diseases of the muscular substance, they
are introduced here, because they are not of sufficient importance
to form a separate chapter. Laennec met with an osseous deposition
between the fibrous and serous layers, which formed a band from
one to two fingers broad, completely encircling the heart, and
sending off triangular processes towards the apex. (De PAuscult.
22*
340 HOPE ON DISEASES OF THE HEART.
torn. ii. p. 675). In other instances, in which the concretion has
formed a similar ring, or a case nearly enclosing the whole organ,,
it has sometimes given off processes which penetrated the muscular
substance, (Latham, Lond. Med. Gaz. vol. iii. p. 7,) and reached
even into the cavities. The general symptoms have been those of
great obstruction of the circulation. Dr. Elliotson relates two cases
in which masses of cartilage connected with the pericardium com-
pressed the pulmonary artery, and created a murmur.
As osseous or cartilaginous degeneration of the heart and peri-
cardium is incurable, the treatment can only be palliative.
Tubercles (see case of a Genevese) and tumours of a carci-
nomatous nature have been found in the substance of the heart.
Recamier has seen the organ converted in part into scirrhous
matter like the skin of bacon, in a subject who had also carcino-
matous tumours in the lungs. MM. Laennec, Andral, Bayle,
Bouillaud, and others, have found cancer in the heart. The total
number of cases recorded amounts to about a dozen.
From these it appears that, in the heart, as in other organs,
carcinomatous productions, both scirrhous and encephaloid, may be
developed in two principal forms, that of isolated tumours, and that
of interstitial infiltration. They rarely exist without similar
productions in other organs, especially the lungs. There can be
no doubt that cancer, if sufficiently extensive, would impede the
action of the heart and obstruct the circulation ; but the cases on
record are too few to afford data for a general history of the disease.
Cruveilhier has delineated melanosis forming numerous tumours
under the pericardium and in the substance of the heart. I have
seen similar cases. Serous cysts and vesicular worms, (apparently
the cysticercus finnus of Rudolphi,) have also been found in the
heart.
[The symptoms of these foreign growths are very obscure, and as but few
of these cases have been examined in reference to the physical signs exhib-
ited during life, we are not yet in possession of any definite knowledge of the
truly characteristic symptoms.
It has been observed that the cases of the encephaloid cancer, or medullary
sarcoma, have been attended by the acute lancinating pain, and the skin to
present the straw colour, or earthy, or sallow hue, indicative of malignant
disease, and that habitual dyspnoea, palpitation, and dropsical effusions were
also present. — P.]
CHAPTER VIII.
ATROPHY OF THE HEART.
Atrophy consists in deficient nutrition, and the heart, like any
other muscle, is liable to it. The heart of an, adult was found by
Burns not larger than that of a new-born infant, and the heart of a
female of twenty-six not larger than that of a child of six. Bertin
gives a similar case (66) : the writer has met with the same ; and
numerous other instances are on record.
DISEASES OF THE VALVES AND ORIFICES. 341
Atrophy generally takes place under the influence of those
causes which produce general emaciation : chronic diseases, for
instance ; as phthisis, diabetes, chronic dysentery, cancer and
malignant affections in general. Excessive bleeding is another
cause. Laennec adduces an instance resulting from the treatment
of Albertini and Valsalva employed to cure hypertrophy. Finally,
protracted compression by fluid effused within the pericardium, as
in cases of chronic pericarditis, may produce the effect, and
Bouillaud relates cases in which the same resulted from compression
by " enormous masses of false membrane" (Traite, i. 448).
The heart, when atrophous, generally contracts upon itself, so as
to diminish its cavities, while its walls do not become materially
thinner, and sometimes become even thicker than natural. In the
latter case, the affection must not be mistaken for hypertrophy, and
the error may be avoided not only by remarking the general
diminution of the volume of the heart, but also the shrivelled and
wrinkled appearance of its exterior.
Atrophy may also co-exist with dilatation, namely, when the
walls are so thin that the total volume of the muscular substance is
diminished.
Diminution of the volume of the heart does not appear to produce
symptoms which entitle it to be ranked as a disease. Individuals
who present this peculiarity are perhaps less subject to inflammatory
complaints than others, though they are more prone to anaemia, to
fainting from slight causes, aud to nervous affections. It is
remarkable that women, who are more subject to these ailments
than men, have in general smaller hearts.
The treatment for atrophy is principally that of its causes ; other-
wise, it is the same as that for dilatation.
CHAPTER IX.
DISEASES OF THE VALVES AND ORIFICES OF THE HEART.
SECTION I. — Anatomical Characters, with predisposing and exciting Causes, of
Diseases of the Valves.
"We resume this subject at the point where we left it at the end
of the section on the anatomical characters of chronic endocarditis,
p. 213.
The valves and chordae tendineae consist, according to the best
authorities, of fibrous tissue interposed between a production and
reduplication of the lining membrane of the heart. The fibrous
tissue is prolonged from a dense, whitish zone of the same, which
encircles each of the orifices of the heart, and is. as it were, the tendon
or point of attachment into which the muscular fibres of the organ
are inserted. The lining membrane of the heart, according to
Bichat, approximates closely in character to serous membranes :
342 HOPE ON DISEASES OP THE HEART.
the valves, therefore, may be said to consist of fibro- serous tissue.
Now, the fibrous tissue in general is remarkable for its proneness
to cartilaginous and osseous degeneration ; whence we derive an
explanation of the fact, that the valves and orifices of the heart
are frequently affected with these degenerations, while the cavities,
where they are invested solely by the lining membrane, are in a
great measure exempt. Though disease occupy a valve univer-
sally, it generally stops abruptly where the serous membrane is
continued from the circular zone, or the extremities of the chordae
tendineas, upon the muscular substance. In a few instances it
advances farther ; but I have never seen it attack the membrane
of the muscular substance without being connected with, and
apparently propagated from, disease of the valves ; and, in these
cases, a conversion of subserous cellular tissue into cellulo-fibrous
had preceded the transformation into cartilage or bone.1
It appears, then, that the disease is dependent for its origin on
the fibrous and not on the serous tissue ; in corroboration of which
view, it may be stated that, where the fibrous tissue is most abun-
dant,— namely, at the base and the free margin of the valves, car-
tilaginous and osseous depositions are the most frequent and ex-
tensive: and again, it is common to find the valves encumbered
with large masses of cartilage from which the internal membrane
can be peeled off in its natural thin and transparent state. In these
cases the surface of the morbid deposition is smooth and equable;
and it is seldom until it becomes corrugated, rugged and knotty,
that the internal membrane is implicated in the disease. Calca-
reous depositions, in the same way, seem always to commence un-
derneath the membrane. In a case under my observation, (Fig. 15,)
in which two rings of bone as thick as writing quills encircled the
1 These present the most familiar instances of Analogous Transforma-
tions, by which term is meant a conversion of one tissue into some other
natural to the system, in contradistinction to cancer, tubercle and others,
which present no analogy to anything in the healthy system, and are there-
fore called non-analogous productions.
But though one tissue may be transformed into another natural to the sys-
tem, it cannot be transformed into any other, but only into certain others.
The laws which regulate the selection are exceedingly curious, interesting,
and instructive; for they are exactly those which preside over the growth of
the human embryo, or are exhibited in the " series of animals." The young
reader is strongly recommended to make himself well acquainted with them
(see Andral's Path. Anat. vol. i. chap. 4). Here, it is sufficient to say that no
transformations are more common than those of cellular tissue into fibrous,
fibrous into cartilaginous, and cartilaginous into osseous. " These aberrations
from the natural nutrition of the part," says Andral, "are preceded in many
cases by irritation, (inflammation,) but neither constantly nor necessarily
so and the knowledge which we now possess on the laws ofembryogony,
as well as of those which regulate the nutrition of different animals, enables us
to conceive how every species of transformation of tissue may occur inde-
pendently of any antecedent irritation" (Ibid. p. 292). The reader is re-
ferred back to chronic arteritis, p, 226, for an account of the circumstances
under which valvular and arterial diseases may not have originated in
inflammation.
DISEASES OF THE VALVES AND ORIFICES. 343
left orifices of the heart respectively, the membrane was stretched
like a blue film over the whole of the aortic, and the greater part of
the mitral ring.
Valvular disease is much more rare on the right, than on tho left
side of the heart. Bichat, indeed, denied its existence at all in the
former situation, but his opinion has been fully disproved. Mor-
gagni, Vieussens, Hunauld, Horn, Cruwel, Corvisart, Burns, Bertin,
Louis, Laennec, Bouillaud, Latham, Clend inning, and many others,
have all met with instances of disease of the right valves. Dr.
Latham thinks that in one-third of the cases in which he has seen
disease of the left valves, it has existed in the right also. Up to the
year 1831, I had notes of eight cases in which it existed in the
right, and I could recollect several others. In six of the eight the
left side was simultaneously affected, and generally to a much
greater extent ; but the proportion which the whole number men-
tioned bore to the cases that I had seen of disease on the left side,
was less than that indicated by Dr. Latham, not exceeding, I think,
one in four and a half to five. Since 1831, 1 have reason to believe,
from the examination of a vast number of cases of valvular disease,
mostly without, but occasionally with dissection, that the proportion
of affections on the right side, as compared with the left, is very
much smaller than I have specified above. I cannot state, nume-
rically, the exact proportion, as I have not leisure at present to
analyse 10,000 cases, which I calculate to yield about four per
cent., or 400 cases, of valvular disease ; but my general impression
is, that, out of the 400, I have not, at the utmost, met with 20 cases
of disease of the right valves, — which would only be five per cent.,
or 1 in 20. Dr. Clendinning has met with about 1 in 1(3, out of
100 cases, as exhibited in the following- statement, with which he
has obligingly favoured me :
Valves of the left side alone, 92 -6, or Tyhs,
right side alone, 2 -1, or tyth,
both sides, 6 -31, or Tyh.
He adds, however, that he neglected to record some instances which
u might fairly be presumed to have occurred mainly, if not exclu-
sively, under the first head." This would reduce his proportion
below xVth> and bring it nearer to mine, namely ^V I suspect, how-
ever, that it will eventually prove to be lower still. It is remark-
able that in all my own cases, except Lady R., and nearly all those
of the authors quoted, (with the exception of Dr. Latham, who is
silent on this point, and Dr. Clendinning, whom I have not had
the opportunity of consulting,) the induration on the right side was
merely fibrous or cartilaginous, and never osseous. When the two ,
sides are affected at once, it very rarely happens that the disease on
the right is greater than that on the left ; in general it is much less,
being comparatively slight or incipient.
Respecting the cause of the remarkable difference which the two
sides of the heart exhibit in their liability to induration, authors
have not been agreed. Corvisart attributed it to a more decidedly
344 HOPE ON DISEASES OF THE HEART.
fibrous organization of the left valves, in virtue of which they are
" more disposed to receive the matter that is to transform them into
cartilage, or the calcareous salts that impart to them an osseous or
stony hardness." MM. Bertin and Bouillaud have ascribed the
difference to the different nature of the blood that traverses the two
sides respectively, the left receiving blood of a more vital, more
stimulating, more irritating quality than that by which the right
cavities are moistened. Laennec does not offer a decisive opinion.
Without pretending to decide whether the latter cause conspires,
or not, to produce the effect, I entertain no doubt that the opinion
of Corvisart is substantially correct ; for I have already repeatedly
shown that it is principally the fibrous tissue which undergoes
transformation into cartilage and bone, both under the influence of
inflammation and independent of it. It also happens that both
these classes of exciting causes, the inflammatory and uninflamma-
tory, are most in operation on the left side of the heart ; for it is
here that endocarditis is of most frequent occurrence, and that the
valves are most strained by the greater power of the left ventricle and
the stronger retrograde pressure of the aortic blood : and it has been
shown at p. 227, that inordinate straining of the valves is a cause
of their hypertrophy and transformation into cartilage and bone.
The appearances of valvular induration are somewhat different,
according as the disease occupies the auriculo-ventricular, or the
arterial valves ; the cause of which is to be found in the difference
which naturally subsists between the valves themselves. I shall
therefore describe the degenerations of the two classes of valves
separately. It may be premised that there is no essential difference
but in degree and frequency of occurrence, between the degenera-
tions on the two sides of the heart; consequently, a description
drawn from the left will apply to the right.
Induration of the Mitral Valve. — The appearance presented by
the indurated mitral valve differs according as the disease occupies
the base, the margin, or the whole of the valve.
When the whole is affected with fibro-cartilaginous degenera-
tion, the valve is generally contracted throughout, and what is lost
in space appears, as it were, expended in thickening the free border;
for this is converted either into a ring, an oval-shaped collar, or a
transverse slit like a button-hole (Figs. 5, 7, 12). The size of the
aperture is various. I have seen it of all sizes from an inch to a
quarter of an inch in its longest diameter. The thickness of the
border likewise varies. I have seen it equal a writing quill. When
the valve is thus contracted, it generally projects more or less, in a
funnel shape, into the cavity of the ventricle. In one case I found
it project so far that the columnae carneae were inserted immediately
into the ring, the chordge tendineas having disappeared. The sur-
face of the induration is smooth, polished, and translucent until the
disease throws out osseous or other excrescences, which, interfering
with the integrity of the investing membrane, render it corrugated,
rugged, and opake. Before ossification takes place, the induration
DISEASES OF THE VALVES AND ORIFICES. 345
described sometimes presents a truly cartilaginous hardness, and
sometimes the consistence of fibro-cartilage, or only that of fibrous
tissue. When divided, the aspect of the section varies according
as the disease is cartilaginous, fibro-cartilaginous, or fibrous.
In a more advanced degree, cartilaginous induration is trans-
formed into imperfect bone. It seldom happens, however, that
more than a very small proportion of the cartilaginous mass is ossi-
fied, and the change takes place sometimes at its surface, and some-
times deep in its substance. The bone produced does not exhibit
the fibrous structure and peculiar arrangement of natural bone;
though, as it contains a large proportion of cartilage, it may be pre-
sumed to possess more or less vascularity and vitality.
There is another species of osseous induration of the valves,
which is essentially different from the above, inasmuch as it con-
sists of calcareous matter in great predominance, and, like vesica]
calculi, has no vitality. It presents itself under the form of small,
polished, and semi-transparent scales; or of minute, yellowish,
opake granules, the agglomeration of which forms concretions of
various dimensions, from a mere point to the size of a horse-bean.
The deposition commences underneath the lining membrane, and
generally in a small patch of indurated, cheese-like steatomatous
matter; the surrounding parts being healthy. The scales lie fiat
and superficial under the membrane, while the granules penetrate
more or less deeply into the subjacent tissues. When either the
scales or the granules enlarge, and their surfaces become rugged or
acuminated, they cause absorption of the internal membrane, and
come in immediate contact with the blood.
Some authors believe that ossifications of this description are
natural to old people, because they occur in the majority of those
who have attained the age of sixty. Whatever be the character of
the ossification, whether it be mixed with cartilage or purely cal-
careous, to me it appears to be a morbid production. The circum-
stance of its occurring in the majority of persons above the age of
sixty, does not militate against this view: for, as the elasticity of
the arterial, as of all the other tissues, is diminished by age, the
valves of the heart and the coats of the arteries are, in the aged,
less capable of resisting the distending force of the blood, and are
therefore more liable to disease. Nor does the circumstance of the
ossification being more calcareous and less cartilaginous in the old
than in the young prove that, in the former, it is a natural change.
It confirms, indeed, what is proved by every part of the bony tissue ;
viz. that in age the ossific tendency is greater; but it does not,
for this reason, follow that the tendency is natural when it dis-
plays itself in an unnatural situation, as in the heart and arte-
ries. I find this opinion expressed in almost the same words by
Andral. " The process of ossification naturally increases in extent
as the individual advances in life: but, notwithstanding the general
physiological nature of this process, it may constitute a true patho-
logical condition, by interfering with the due accomplishment of
346 HOPE ON DISEASES OF THE HEART.
vital function, as in certain cases of ossification of the heart and
arteries" (Path. Anat. i. 368).
'Sometimes the membranous portion and free margin of the valve
are health}', while the fibrous zone at the base is cartilaginous, or
beset with small calcareous incrustations, or, as sometimes happens,
its whole substance is converted into a thick ring of bone (Fig. 15).
By these depositions at the base of the valve, the orifice is more or
less contracted, while the valve itself may remain capable of clos-
ing. In many cases, again, the base and middle are sound, and the
free margin alone is diseased, its conical processes forming adhe-
sions with each other, and contracting the circumference of the
valve to such an extent as almost completely to close the orifice
(Mrs. — 1 — n). It is not uncommon to find the margin studded
with vegetations, small cartilaginous nodules, or roundish calcareous
granules, which prevent the accurate adaptation of the edges to
each other, and allow regurgitation during the ventricular contrac-
tion. Sometimes, the only diseased appearance that the valve pre-
sents, consists in brittle scales or patches of pure phosphate of lime
between the two component layers of the membranous portion, which
they occasionally rupture, and thus come in immediate contact with
the blood. Sometimes, again, the only material lesion of a valve is
shortening and thickening of the tendinous chords, which prevent
the valve from completely closing during the ventricular systole
(Fis:s. 5, 7, and 12). This was unknown as an important lesion
till it was pointed out in the first edition of this work; and, even
up to the present day, I see it perpetually overlooked in the dissect-
ing-room by those whose attention has never been specifically
directed to it : yet, from being attended with regurgitation, it consti-
tutes one of the worst varieties of disease of the valves.
Sometimes, though rarely, the same regurgitaion is occasioned
by one of tiie membranous expansions of an auricular valve having
adhered, by inflammation, to the walls of the ventricle ; and it is
principally the posterior layer that becomes thus adherent, because
it is less moveable.1
Another affection of the valves, whether auricular or semilunar,
occasioning regurgitation, is atrophy. By this, I have seen the
membranous expansions of the mitral valve reduced to a mere re-
ticulated web, and the aortic valves perforated in five or six places.
The affection commonly occurs in connection with general atrophy
and anaemia. It has been fully described by Dr. Kingston (Medico-
Chirurg. Trans.).
I may here add, that, without any disease whatever of the valve
itself, regurgitation may take place when, in consequence of dilata-
tion of the auricular orifice, the valve is not large enough to close
it — a condition of parts which I have occasionally met with in cases
of great dilatation of the left ventricle.
1 M. Bouillaud is mistaken in supposing himself the discoverer of this ad-
hesion (See his Traite, ii. 188). Dr. Elliotson described it five years pre-
viously in his Lumleyan Lectures.
DISEASES OF THE VALVES AND ORIFICES. 347
Induration of the Aortic Valves. — Induration of the aortic
valves, like that of the mitral, is more frequent and extensive at the
base and free border, than in the intermediate space. At the border,
it originates more especially in the corpora sesamoidea, because they
contain more fibrous tissue : hence these bodies are sometimes
enlarged by cartilage to the size of peas. I have seen the margin
contracted by fibro-cartilage into a ring a quarter of an inch in
diameter. (Hedgley, Fig. 17). I have seen the margin of the
individual valves thickened and contracted, so that they were too
small to close the orifice (See Figs. 6 and 14). I have seen the
corners of the valves adhere, from inflammation, to the arterior
walls, so as to leave an interval between each two valves, which
permitted regurgitation (Fig. 11, b). 1 have seen a similar inter-
val occasioned by an aneurism of the aorta stretching the origin of
the pulmonary artery where the affected valves were seated (Fig.
12, b). The valves are sometimes thickened, nodulated and cor-
rugated by an opake yellow degeneration, consisting of a mixture of
cartilaginous and steatomatous matter. I have repeatedly seen the
angles of the valves detached from their bases and partially wasted
away by this degeneration ; so that, adhering by their centres only,
they hung loose into the artery, and were destitute of fulcra by
which to oppose the reflux of blood from the aorta (Copas). In
Fig. 14, A, they hung loose into the ventricle, and two valves
were together. In another instance, the same disease had under-
mined and more or less detached the bases of all the valves
throughout nearly their whole length ; and. under one of them, it
had led to the formation of a canal, as wide as the little finger,
beneath the lining membrane of the heart, leading to an aneurism
in the muscular substance of the septum between the left auricle
and ventricle (Case of Brown). The same is seen in Fig. 20. I
have once seen the edge of a valve rent, so that a flap hung back
and allowed regurgitation (Fig. 1 1, a). The same valve contained
a perforation (Fig. 10, a).
Such are the cartilaginous and steatomatous degenerations of the
aortic valves. The osseous, of which we have next to speak, are
perhaps as frequent in the aortic as in the mitral valves. The
ossification may be either pure, or combined with cartilage. In
one case under my observation, an irregular, scabrous, and denuded
concretion, the size of a pea, occupied the edge of one of the valves,
and projected into the cavity of the artery. (Porter, Fig. 16). In
another case, a similar mass, of a conical shape, sprang from the
base between two of the valves, and presented its apex towards the
centre of the vessel. (May). Smaller concretions of this de-
scription, and in this position, are common. M. Bertin saw an
ossification of one of the aortic valves which had attained the size
of a pigeon's egg (Obs. 53). In one of my cases, already alluded to,
the fibrous zone encircling the base of the aortic orifice was converted
into a ring of bone as thick as a quill (Fig. 15).
When the ossification is confined to the margin and base, while
348 HOPE ON DISEASES OF THE HEART.
the middle portion is still healthy over a certain extent, the valve, if
its thickening is not very considerable, may still rise and fall and
not offer any marked obstacle to the circulation. But when the
ossification pervades the middle portion of the valves, they shrink,
become soldered together, or curl up upon themselves, in the direc-
tion either of their concavity or convexity, so as to present a rude
representation of certain sea-shells. In this state they may become
immoveable. If curled forwards, they remain applied along the
walls of the aorta, and oppose no other impediment to the course of
the blood than what results from the thickness of the ossification.
They then permit regurgitation. If curled backwards, they remain
fixed in the fallen or shut position, and considerably contract the
orifice, as well as permit regurgitation (Fig. 18). Not unfrequently,
one of the three valves is curled in an opposite direction to the
other two. Corvisart has seen all three ossified in the closed
position, and they would only have left an extremely narrow cleft
for the passage of the blood, had not one retained sufficient mo-
bility at its base to perform a movement which augmented, by a line
or two, the width of the cleft.
Induration of the Valves at the right side of the Heart. — In-
duration of the right or venous valves is, as already stated, almost
always simply cartilaginous or fibro-cartilaginous, (Fig. 12.) and is
comparatively rare, not existing in perhaps more than about one case
in sixteen, twenty, or more, of disease in the left valves. It seldom
presents itself without being accompanied by disease of the left
valves also, and it is, in general, less advanced than the latter
(Anderson, Sharpe). The tricuspid is more frequently affected than
the pulmonic valves. I have never seen the latter diseased, but
I have once found them incapable of closing the orifice in conse-
quence of dilatation of the artery, (Weatherly,) and I have seen the
orifice contracted to the diameter of a quill, an inch below the valves
(Collins). M. Berlin has seen the valves themselves contracted into
a circular aperture only two lines and a half in diameter. A few
other lesions foreign to the valves themselves have been described at
page 100. As already stated, disease of the right valves, whether
cartilaginous or osseous, only differs from that of the left in frequency
and extent, its characters being essentially the same.
Predisposing Causes of Valvular Disease. — These are, the
larger proportion of fibrous tissue in the valves of the left side ;
advanced age, a cachectic state of the system from inebriety, mercurio-
syphilitic disease, gout, hard labour, insufficient food, &c.
Exciting Causes. — 1. Inflammation of the internal membrane of
the heart, generally connected with acute rheumatism. This is
the most frequent and important cause. It is fully noticed under
the anatomical characters of endocarditis, pp. -210 and 213.
2. Such causes as overstrain the valves by increasing the force of
the circulation ; namely, violent and long-continued corporeal efforts,
hypertrophy with dilatation, protracted nervous palpitation. These
causes occasion hypertrophy of the fibrous tissue of the valves,
CAUSES OF WARTY VEGETATIONS. 349
which may subsequently pass into cartilaginous and osseous disease.
They are more fully considered at p. 226. In a few cases, I have
known violent efforts occasion laceration of a valve, and the injury
has induced endocarditis. The immediate symptoms are noticed
at p. 202.1
SECTION II.— Anatomical Characters and Causes of Warty Vegetations of the Valves.
These excrescences bear a close resemblance to venereal warty
vegetations on the external organs of generation. Their form is in
general irregularly spherical, oval, or cylindrical : their size varies
between that of a small pin's head and a large pea, but when isolated
they are occasionally as large as a horse bean. Their surface is
polished, but often lobulated like a raspberry : they are found either
isolated, in clusters, or in closely agglomerated patches like cauli-
flowers. Their number is various : sometimes there are only one
or two, and sometimes they pervade the whole of the valves, the
tendinous cords and a great portion of the auricle (Dolan). Their
colour, occasionally of a greyish or yellowish white, is more com-
monly heightened, universally or in parts, with pink or red of greater
or less depth. Their texture is fleshy and slightly translucent, like
the exuberant granulations of an ulcer. Their consistence is
variable ; in general they are soft and humid, as if only recently
and imperfectly organized ; and they can then be easily scraped off
with the handle of the scalpel; but sometimes they are firm, like
fibro-cartilage, creak under the knife, and cannot be detached
without tearing with the nail, or cutting with the edge of the
scalpel. Firm vegetations are generally larger and more truly
warty than soft.
The internal membrane of the part from which vegetations
spring, is almost invariably more or less diseased. It is thickened,
steatomatous or cartilaginous, ossified, ulcerated or ruptured.
When vegetations grow from a diseased, but unbroken surface,
they may be numerous, and occur in several parts at once; but
when they grow from a ruptured or ulcerated edge, they are few
in number, often not exceeding one or two, are generally confined
to that edge exclusively, and attain a larger size than any others.
I have seen them exceed a horse-bean, and with a neck two,
three, or four lines long. It cannot be doubted that their origin
is connected with the broken state of the membrane.
The base and free margin of the valves appear to be peculiarly
favourable to the growth of warty vegetations. Along these parts,
but especially the latter, they are often arranged in a single row.
They occur on both sides of the heart, but less frequently on the
right. The aortic and mitral valves are the parts most subject to
them. They are more rare in the auricles than on the valves,
1 Other cases of ruptured valves have been described by Adams, Cheyne, and
Townsend. On rupture of the heart itself, see Diet, de Med. Cceur, Rupture,
by Ollivier.
350 HOPE ON DISEASES OF THE HEART.
especially in the right auricle. I have, however, seen one-third of
the left auricle completely covered with them. (Dolan). When
situated at the base, or the free margin of a valve, they encumber
its movements, prevent its closure, and contract its aperture accord-
ing to their size and number.
Laennec thought it " indubitable that vegetations were nothing
more than small polypous or fibrinous concretions, which, being
formed on the sides of the valves or auricles, become organised by
a process of absorption or nutrition analogous to that which con-
verts albuminous false membranes into adventitious membranes or
cellular tissue." This opinion is unsatisfactory ; for, as polypi are
most common in the right cavities of the heart, vegetations ought to
be so likewise, — the reverse of which is the fact. The valves,
moreover, being perpetually in motion, would be the last parts to
which albuminous concretions would adhere, as it is a stagnant
state of the blood which is most favourable to their formation ; yet
the valves are the parts most subject to them. We most commonly
find real sanguineous concretions, when of small size, amidst the
-intricacies of the columnas carness, where the blood is more stag-
nant than elsewhere. Finally, if vegetations were merely fibrinous
concretions, instead of being rare, they ought to be frequent; for,
as the circumstances which, on this view, lead to their formation,
are common to all persons labouring under an obstructed circula-
tion, all, or, to say the least, many, should be affected with them.
These considerations, then, render it highly improbable that vege-
tations are formed by mere coagulation of the blood under ordinary
circumstances.
Kreysig attributes their formation to inflammation. MM. Bertin
and Bouillaud have espoused the same opinion, resting on the fact,
that vegetations bear a close analogy to albuminous granulations
occasionally found on serous membranes affected with chronic
inflammation. The small and soft vegetations certainly bear this
analogy — a fact of which I have satisfied myself by comparing the
two as occurring in the same subject. I have also produced these
vegetations in the space of an hour, by lacerating the pulmonic
valves and interior of the right ventricle with the point of a hook,
in an ass poisoned with woorara ; (see Autopsy, p. 58 ;) whence I
think it highly probable that they were occasioned by an exudation
of coagulable lymph ; for we know that it may exude from the sur-
face of a cutaneous abrasion or cut within the brief period specified.
The inflammatory origin of vegetations, moreover, is countenanced
by the fact that the internal membrane of the part from which they
spring, is almost invariably more or less thickened, steatomatous,
cartilaginous, ossified, or ulcerated — lesions which most frequently,
though not always, result from inflammation-: and, further, since
the signs of endocarditis have been well understood, it has occurred
to myself and others to find that vegetations have generally been
preceded by some tolerably distinct attack of that inflammation,
usually in connection with a rheumatic fever.1 There are proba-
1 See the remarkable ease of Fenn.
CAUSES OF WARTY VEGETATIONS. 351
bly two modes in which inflammation has the effect of producing
the vegetations: 1. by effusing coagulable lymph, which becomes
organised, precisely as we see globular granulations produced on the
pleura, pericardium, or peritoneum; 2. by imparting to the blood
in contact with the inflamed part a morbid tendency to coagulate —
a tendency which may be legitimately inferred to exist here, because
we know, from positive observation, that it exists in local inflam-
mations of veins and arteries, and because the fatal cases of acute
endocarditis related by M. Bouillaud have actually shown that, in
this affection, the blood frequently coagulates before death, and
forms colourless, adherent polypi. Now, admitting that its fibrine
has this morbid tendency to coagulate, it is very conceivable, as M.
Bouillaud suggests, that it may be deposited on the tendinous cords
and edges of the valves, agitated by alternate movements, just as we
see it deposited on the rods with which we beat blood. Once
deposited, it naturally becomes organised.
With respect to the large, dense, and more properly wart-like
vegetations, it is consistent with analogy to suppose that their nutri-
tion has undergone some of the capricious modifications or perver-
sions, which we so frequently witness in chronic inflammation, and
which may have caused their transformation into a dense, cellulo-
fibrous tissue. Possibly; the greater friction and agitation to which
large vegetations are subjected, may be the source of their altered
nutrition.
The resemblance which the firmer valvular vegetations bear to
venereal warts, led Corvisart to think that they might have the
same venereal origin. This opinion, however, is not tenable ; as
extensive observation in venereal hospitals has proved that vegeta-
tions of the heart are not more common in persons affected with
this disease than in others; and it is certain that they have occurred
in numbers who had never been in the least degree tainted with
the disease.
[" Diseases of the orifices and their valves are of very considerable variety,
but those that interfere with the office of the parts which they affect may
be reduced to two classes — those that more or less obstruct the current of the
blood in its proper channel, and those that occasion it to take a reversed di-
rection. The former, for brevity, I term obstructive, the latter, regurgitant
lesions.
"The most common change in the valves is thickening, which presents
itself chiefly under two forms: — 1. A softer kind of thickening, in which
the valves retain much of their pliability; 2. An opake thickening, with
more or less induration, so that the valves become less flexible and mobile
than usual. The first occasionally affects the semilunar valves, but rarely
the auricular. It appears to be the product of inflammation chiefly affecting
the serous membranes of the valves, and is produced by organised lymph
between their layers, or upon their exterior, from which it often may be
separated. This deposite is generally seen less at the margins than at the
middle and attached parts of the semilunar valves, chiefly on their ventri-
cular sides, and occasionally forming a bond of adhesion between two ad-
joining valves, which are glued together as far as the corpora arantii. This
constitutes a form of slight obstructive disease of the arterial orifice. I have
in a few cases seen the same deposite on the layers and cords of the auricular
352 HOPE ON DISEASES OP THE HEART.
valves, here and there causing them to adhere, and forming a false mem-
brane on their auricular surface.
" The opake tough thickening of the valves is the most common, and is
frequently combined with the former. When occurring simply, there is a
smoothness of the, exterior, which, with the character of the thickening
material, seems to indicate that it is chiefly between the serous layers of the
valves, and probably arises from disease in the fibrous tissue, that forms the
strengthening web of the valves. This thickening commonly affects the
semilunar valves to their very margins, and is sometimes seen extending
into the ventricular lining, and perhaps forming there slight ridges where
the bands of fibrous tissue cross the muscular walls. With the laminae of
the auricular valves it commonly involves their orifices and part of the
auricular lining, and extending into the tendinous cords, which are irregu-
larly thick and knotty, and their fleshy columns are likewise occasionally
changed into fibrous cords. With this more rigid thickening there is often
combined a contraction or elongation of some parts, or both, affecting dif-
ferent parts; and it is such changes of proportion that so commonly injure
the proper action of the valves and orifices. Mere thickening, unless it be at-
tended with great stiffness, will not materially injure the office of the valves ;
but. changes in form and proportions necessarily must. In the lesions
affecting the mitral valve, you may perceive how the shortening of a few of
the tendinous cords throws the rest into a loose state, in which they cannot
draw the membranes of the valve smooth on each other; hence they form
folds and chinks, through which the blood must regurgitate at each systole.
Again, where portions of the valve and their cords are elongated and en-
larged, so that they may be forced backwards towards the orifice, by keeping
the valve partially open, also occasion regurgitation. Further, when the
two laminae of the valve are thickened, contracted and adherent, a sort of
narrow funnel-shaped tube, instead of a valve, is formed, both retarding the
flow of blood from the auricle into the ventricle, and never closing against
its reflux into the auricle. This forms both obstructive and regurgitant
disease of the mitral orifice. In this manner the left auricular orifice is
sometimes so contracted as not to admit a little finger; naturally it admits
with ease two full sized fingers. Here again, in the aortic valves, you see
one of them contracted at its free margin, so that it could not meet its fel-
lows, but left a chink through which the blood regurgitated with a murmur
into the ventricle at each diastole. I have known the same effect to arise
from this kind of disease preventing the equal dilatation of the valves.
When a ventricle with its orifice is dilated, the semilunar valves are gene-
rally dilated with them, so that the proportions are preserved ; but if there
exists in one or more of these valves a rigid thickening that will not yield,
the dilatation of the orifice renders them insufficient; they cease to close the
orifice completely, and consequently regurgitation takes place through them.
Again, an uncommon elongation of the free margin or attachment of one or
two of the semilunar valves, so that these margins, instead of being closed
against their fellows, become retroverted under them, constitutes another
form of regurgitant disease of the semilunar valves, of which I show you
here several specimens. The valves appear to have given way generally
at their attachments to the artery, perhaps from the yielding of its fibres and
the formation of a slight pouch in it; but you see the effect is to destroy an
attachment of two of the valves, which, instead of forming bags, are either
retroverted, or contracted and thickened, on a line with the ventricular con-
vexity of the other valve. In these cases probably rupture of some fibres
may have at some time taken place, and accelerated the change; but it is
always associated with more or less of the thickening of which I am now
speaking.
"To the thickening of the valves and orifices there is frequently added
great induration and even ossification; and this alone may constitute disease,
generally of the obstructive kind. As such, it often affects the aortic orifice,
CAUSES OF WARTY VEGETATION. 353
particularly at the attached portions of the valves, and at the curves of the
artery, which form the boundary of the little recesses or sinuses into which
they retire. If in either of these situations a rigid portion project into the
current as it passes, it constitutes obstructive disease, and may cause a con-
stant murmur with each pulse ; or if the whole ring be rigid and unyielding,
it may, under the circumstances of greatly increased action, constitute a
constriction, the vibrating resistance of which, opposed to the current, may
give a murmur. Sometimes the whole of the valve is so rigid that it must
have opposed more seriously the passage of the blood. In these drawings
you see aortic valves which are ossified, and have adhered at their edges so
as to leave only a little aperture at their middle, where their margins were
loose and permitted the blood to pass.
"The lesions which I have been describing are the most common forms
of disease of the valves; they are mostly of a chronic character, and in the
greatest number of instances originate in the rheumatic endocarditis. Their
effects on the circulation and on other functions have been generally propor-
tioned to their degree and character, the rapidity of their productions, and to
their complication with hypertrophy and dilatation or other disease : hence
they may vary infinitely; they may exist and produce cognizable signs
without obviously deranging the heatt's action, or in an overt direct manner
injuring the health ; and they may cause the most distressing and dangerous
symptoms, and sooner or later prove fatal.
"There is another kind of thickening to which the valves are subject,
accompanied with softening, ulceration, and often rupture. This is fortu-
nately not very common, for it is a terrible disease, destroying the valves.
chiefly the aortic, in the course of a few weeks; and soon after proving fatal.
This occasionally supervenes on older disease which has originated in rheu-
matism ; but I have in several instances known it to arise independently of
rheumatism, perhaps after a severe cold, or violent strain, especially in
persons who have been addicted to spirits. The ruptured or ulcerated por-
tions of the valves are found loaded with ragged, soft, fragile vegetations,
more or less tinged with blood, and these are also sometimes seen adhering
to adjacent parts where the endocardium is entire. The remaining parts of
the valves are much thickened, of an opake yellowish white, with a pink
hue, and pink patches are often seen in the aorta, with atheromatous thicken-
ing. I think that these changes may be viewed as the effects of acute in-
flammation affecting all the tissues of the valves. In these two drawings
you see specimens of its ravages. In this, all three aortic valves have been
completely broken up, and their torn margin fringed with thick vegetations
hung down into the ventricle. In this, again, you see one of the valves has
given way at its centre, and its margin, thickened and loaded with vegeta-
tions, lies like a cord across the mouth of the artery, whilst the lacerated
attached portion is retroverted into the ventricle, and, with part of the
lamina of the mitral valve near it, is covered with vegetations. In other
cases I have seen smaller perforations, probably ulcerations, both in the
middle of the aortic and in the mitral valves, always fringed with vegeta-
tions. The smooth perforations so common at the free margin of the semi-
lunar valves are of a different character, and not dependent on the same
cause. I believe that in time the vegetations just described, may become
organised, forming the cartilaginous or fibrous little bodies which have been
called warty excrescences, in which osseous matter is often formed, and
which generally have more recent vegetations attached to them.
" Lastly, we have another class of valvular diseases that have been very
commonly overlooked. I mean atrophy, or wasting of the valves, by which
their membranous portions may become shortened or perforated, and the
tendinous cords withered and absorbed away. The semilunar valves, both
aortic and pulmonary, present these in the most obvious manner in the oval
perforations, at their free margins. You see in these drawings several
specimens. The perforations are oval or rounded, with their edges quite
11— d 23 hope
354 HOPE ON DISEASES OF THE HEART.
smooth and thin, as is also the whole valve. In fact, though there may be
partial deposites of false membrane on their ventricular surface, the valves
are most commonly very thin and flaccid when they present these perfora-
tions ; and in other parts there may be seen still thinner spots, that are sepa-
rations of the fibrous web, and are all but through the serous membrane
also. Now so long as these perforations are confined to so much of the
margin of the valve as closes against that of its fellow, they may not pro-
duce regurgitation ; and this is very commonly the case. In the mitral
valve, the wasting usually effects the posterior portion, the membrane of
which is often annihilated by it, the cords being inserted directly into the
auricular ring. The anterior lamina is also occasionally found much
shortened, and without those five thin expansions of membrane which com-
monly unite the cords with each other, below their insertion into the thicker
part of the valve. It is pretty plain, that with this state of the valve, if
there be not habitual regurgitation, inordinate action of the heart, or slightly
disturbing circumstances, may induce it, especially if there be at the same
time dilatation of the orifice. I have known a murmur produced by flatulent
distention of the stomach, and by certain postures, which 1 have been in-
clined, for reasons to be explained afterwards, to refer to this kind of imper-
fection of the mitral valve. I have found these atrophied conditions of the
valves in cases where there was no trace of previous inflammatory affections
of the heart. In one case there was no other thoracic disease at all, the
patient having died of fever; and attention was turned to the heart only in
consequence of there having been many heart-symptoms, with a constant
blowing murmur below the left breast, during life. In some cases the
smooth perforations have been found in valves thickened by inflammation,
probably of more recent date." — C. J. B. Williams's Lectures, <$-c— P.]
SECTION III.— Pathological effects of Disease of the Valves, and mode of their
Production.
Diseases of the valves, whatever be their nature, whether osseous,
cartilaginous, or warty, have for their common effect, to obstruct
the orifices of the heart ; and this they do, either by contracting the
apertures, or by encumbering the valves in such a manner as to
prevent them from opening and closing with suitable accuracy and
facility; whence there results, either an impediment to the direct
flow of the blood through the aperture, a regurgitation, or both. A
mechanical obstacle is thus presented to the circulation, and, from
the obstruction and embarrassment which it occasions, are derived
the symptoms of valvular disease.
The general symptoms, however, when of an aggravated nature,
are seldom dependent on the valvular obstruction exclusively ; they
are partly attributable to a co-existent disease of the muscular appa-
ratus of the heart. For, so long as the organ remains free from
dilatation, hypertrophy, or softening, the valvular disease, accord-
ing to my observation, is not in general productive of great incon-
venience.1
1 This opinion is strongly opposed to the favourite.doctrine of MM. Bertin
and Bouillaud, and of M. Bouillaud in his later work: namely, that the
symptoms of a retarded circulation are, under all circumstances, the result of a
mechanical obstacle to the course of the blood, as a contracted valve, aortic
aneurism, &c. The errors of this doctrine, and the inconsistency of M.
Bouillaud in maintaining it, have been pointed out at p. 253, and 297, note.
PATHOLOGICAL EFFECTS OF DISEASE OF THE VALVES. 355
This opinion is founded on the following grounds. I have seen
individuals, who were affected in an eminent degree with disease
of the valves or of the aorta, maintain for years a very tolerable
state of health so long as there was no hypertrophy or dilatation of
the heart: but, in proportion as these supervened, the symptoms of
valvular obstruction became more and more developed, and even-
tually assumed their most aggravated form.
I have reason to believe that, in these cases, the symptoms were
attributable in a great measure to the hypertrophy or dilatation,
because I have seen a greater val vular contraction produce less severe
symptoms when the hypertrophy or dilatation was less considerable.
It might be supposed that a great degree of contraction would of
itself suffice to produce the symptoms of an obstructed circulation
in their most aggravated form. This is highly probable, but it
does not easily admit of demonstrative proof, as a great degree of
contraction is perhaps never found, on dissection, without hyper-
trophy or dilatation. I therefore infer that these affections ensue
as consequences of valvular contraction, and I believe, for the reasons
above assigned, that they play an important part in the production
of the symptoms.
It is of immense practical importance to keep in view the facts
stated, namely, that valvular disease does not produce formidable
symptoms until it has given rise to hypertrophy or dilatation ; and
that it invariably leads to these affections, unless the circulation is
kept tranquil. We thus know that the most efficacious treatment
of valvular disease consists in employing such prophylactic mea-
sures as are calculated to prevent the supervention of hypertrophy
or dilatation, the latter usually with softening ; and employing them
with the same uncompromising strictness before those affections
have appeared, as if they actually existed.
It remains to be explained how dilatation and hypertrophy
aggravate the symptoms of valvular obstruction. I have shown
(see Dilatation, p. 296) that dilatation of the heart, by enfeebling
the contractile power of the organ, constitutes as truly an impedi-
ment to the circulation, as a more direct mechanical obstacle.
When, therefore, dilatation exists in addition to such mechanical
obstacle, it is clear that the symptoms, having a twofold cause, must
be doubly severe.
Hypertrophy aggravates the symptoms of valvular obstruction,
because the heart, being morbidly irritable, struggles against the
obstacle and falls into fits of palpitation ; and as, during these, a
greater quantity of blood than natural has to be transmitted through
I have had the satisfaction of seeing the opposite opinion in the text, come into
pretty general favour in this country. One of the latest writers is Dr. Clendin-
ning. After examining a great number of cases in the St. Mary-le-bone Infir-
mary, he writes to me, in reference to 100 cases of valvular disease, that he has
"come to the conclusion, whether erroneous or not, that the paramount
element in cardiac pathology is muscular hypertrophy."
23*
356
HOPE ON DISEASES OF THE HEART.
the contracted aperture, or is driven retrograde with augmented
violence, the circulation is performed with increased difficulty.
It-is in consequence of these reciprocal reactions of the valvular
and the muscular apparatus on each other, that cases thus compli-
cated are more severe than any others ; and that capillary embar-
rassment, with dropsy, &c, supervenes at an earlier period, and
attain a greater degree.
From what has been said here and in the parts referred to in the
preceding note, the reader will judge how totally MM. Bertin and
Bouillaud, and more recently M. Bouillaud, have been wrong in
referring the obstruction of the circulation to the valvular contrac-
tion exclusively, without allowing that hypertrophy, and scarcely
that dilatation, contributed in any degree to the effect. Such a
doctrine is not only erroneous, but dangerous, as it leads to perni-
cious practice. For, imagining the valvular contraction to be the
only formidable part of the complaint, to it alone those authors
direct their attention ; and, acting on the inaccurate presumption
that it is, in almost all cases, caused by, and accompanied with, in-
flammation, they attack it with blood-letting, general and local, ab-
stinence, digitalis, &c, — means which cannot remove valvular
disease when once established, and which are, therefore, a useless
expenditure of the patient's strength. It is true, indeed, that mea-
sures calculated to diminish the force of the circulation are useful
in obviating the supervention of hypertrophy or dilatation — the
paramount source of danger in these cases ; but measures employed
for this purpose, and which must be continued for an indefinite
length of time, cannot be practised with the same activity as for the
purpose of curing an inflammation. I would not be understood by
this to mean, that valvular disease is never accompanied by inflam-
mation, and that, when so accompanied, it should not be treated by
antiphlogistic measures : but I mean that they should not be em-
ployed unless there is reasonable evidence of inflammation, — a sub-
ject which has already been fully considered under the head of
chronic endocarditis (see p. 219).
[" The valves of the left side of the heart are far more commonly diseased
than those of the right. Yet occasionally the latter do present the same
changes as the left valves, but it is very rare that they are alone affected, or
in a much greater degree than the left. Nor can you wonder at this when
you consider the function, structure, and relation of the left side of the
heart as compared with the right. Its function requires that it should be
endowed with much greater strength, that it may propel the blood through
the great circulation ; and this greater strength exposes its parts to more
violence from its own movements. Then, to bear this violence, its valves
and orifices are furnished more abundantly with a strengthening fibrous
tissue; yet this very tissue is obnoxious to inflammatory affections, which
tend peculiarly to alter it. A tissue which protects Jby its strength cannot
be endowed with high vitality ; as its vitality is low, so is its natural repara-
tory power slow, and the hastening of this process by inflammation changes
the nature and strength of the material.
" Hence there is deposited no longer the fine, even, transparent, capillary
fibres, which only glisten into view with a silvery whiteness when they are
GENERAL SIGNS OF DISEASE OF THE VALVES. 357
bundled together in numbers, but an opake, yellowish white, thick, tough
material, partly fibrous and partly amorphous, possessing neither the strength
nor the delicate flexibility of the original texture, and consequently injuring
the apparatus by its bulk, its stiffness, or its liability to extension or con-
traction, laceration or rupture. Then the very perfectness of structure, that
gives to the left ventricle a superiority, in point of strength, over the right,
exposes it more to the effects of violence or excessive action. When the
right ventricle becomes distended, you have seen that its auricular valve
opens and permits a partial reflux ; but the mitral valve of the left ventri-
cle is made to close perfectly, and to bear the whole strain of the muscular
fibres contracting on the blood. Again, the pulmonary valves are exposed
to pressure from the tension of the pulmonary vessels only, which are ex-
posed to little pressure but that of the expiratory forces ; but the aortic valves
receive the strain of the great arterial system, liable as this is to violent in-
ciease from the pressure of the muscles of the body, and of any sudden blow
or impression on regions containing its larger branches. You will not
wonder, then, that the valves of the left ventricle should be more frequently
and more extensively diseased than those of the right. You have rather
reason to wonder that they suffer so little, and how they can stand so well
and so long the strain to which they are exposed, particularly when disease
has once begun in them. I believe that they do suffer much more frequently
than is generally supposed, and that many of the circumstances which we
noticed as causes of inordinate action of the heart, do often irritate, or
mechanically strain and injure the membrane covering the valves, and
excite a temporary inflammation in it. How else are we to account for the
partial thickening so commonly seen, especially in the aortic valves, even
where there had been no history of any complaint particularly affecting
them? That such a thickening has been slight and harmless, we may
ascribe to the perpetual motion of the valves and sweep of the current,
which generally prevent any accumulation of deposite that is not connected
with an intense inflammation, or one affecting the subserous tissues. But
occasionally circumstances may favour an accumulation; thickening and
rigidity may take place; and thus the disease will now and then begin in
the valves, independently of rheumatism or any other common cause, and
gradually infringe on the integrity of their functions. The atrophous form
of disease, however, which produces the thinning and oval perforations in
the semilunar valves, and wasting of the membranous parts and tendons
of the auricular, is commonly met with in either compartment of the heart.
It was on the right side that I have seen it attain the greatest degree, hav-
ing reduced the membranes of the tricuspid to mere fringes, and the margins
of the pulmonary valve to a net-work of threads. But even such disease
on this side of the heart produces less prominent symptoms than slighter
lesions on the other." — C. J. B. Williams's Lectures, $c. — P.]
SECTION IV. — Signs, Diagnosis, Prognosis, and Terminations of Disease of the
Valves.
General Signs of Disease of the Valves. — Whether the disease
be fibrous, cartilaginous, osseous, or consist of vegetations, the
general symptoms are the same, if the degree of contraction or re-
gurgitation be equal. Keeping in view the principles developed in
the preceding section, which ought to be read in connexion with
the present, I should assign to disease of the valves, as its general
symptoms, 1. a greatly aggravated form of the same as have already-
been assigned to dilatation of the ventricles; 2. certain peculiar and
distinctive signs, which I shall presently describe.
1. Briefly to recapitulate these symptoms— they are, cough, co-
358 HOPE ON DISEASES OF THE HEART.
pious watery expectoration in many cases, dyspnoea, orthopncea,
frightful dreams and starting from sleep, oedema of the lungs, pul-
monary congestion and apoplexy, passive haemoptysis, (i. e. sputa
stained with dark or g ruinous blood, which occurs especially in
great contraction of, or regurgitation through, the mitral valve,)
turgescence of the jugular veins, lividity of the face, anasarca and
dropsies in general, which in this form of disease attain their utmost
degree ; injection of any or all the mucous membranes ; passive
hemorrhages from the same membranes ; engorgement of the liver,
spleen, <fcc, and congestion of the brain with symptoms of oppres-
sion, sometimes amounting to apoplexy ; occasionally, cerebral
hemorrhage.
The reader will understand that this is an enumeration of all the
worst symptoms of an advanced case. In the early stages the he-
morrhages and dropsies are generally absent, and the congestive
symptoms are less marked.
When the left valves are obstructed, or permanently open, the
pulmonary symptoms of the above category result from engorge-
ment of the pulmonary vessels: when the obstruction or patescence
is in the right valves, they result partly from engorgement of the
bronchial veins, and partly from the quantity of blood transmitted
into the lungs not being adequate to their demand, whence there is
insufficient oxygenization, and its consequence, dyspnoea. In the
latter case, haemoptysis is more rare.
The symptoms affecting the system in general result from re-
tardation of the blood in the venous system.
2. The peculiar and distinctive signs of valvular disease are the
following : — ■
a. When the disease is combined with hypertrophy or dilatation,
as is almost invariably the case sooner or later, the symptoms are
more severe than those of an equal degree of hypertrophy or of di-
latation alone, the paroxysms of palpitation and dyspnoea in par-
ticular being more violent, more obstinate, and more easily excited.
b. Diseases of certain valves impress well-defined peculiarities
on the pulse. This subject has been very imperfectly understood,
and it is therefore necessary to warn the student against the erro-
neous statements which he will find in various authors. The ori-
ginal genius of Corvisart attempted to connect peculiarities of the
pulse with diseases of the heart ; but, destitute of the light of aus-
cultation, he signally failed in the particular applications. The
illustrious father of auscultation, seeing the failure of Corvisart,
seems to have abandoned the attempt. He devotes nearly a whole
chapter to proving that " the exploration of the pulse is far from
being able to give an idea of the general circulation, and cannot
make known the manner in which it is carried on even in the
heart" (vol. ii. p. 473 — 9). He seldom, therefore, mentions the
pulse, except as a quotation from Corvisart and others, to display
its fallaciousness. MM. Bertin and Bouillaud believed that, in con-
traction of the valvular orifices, the pulse was valueless as a sign,
GENERAL SIGNS OF DISEASE OF THE VALVES. 359
quoting Corvisart to display how totally he was deceived in it, and
contending that the auscultatory signs of Laennec were the only
indications of valvular disease worthy of confidence (Traite, p.
225). Dr. Elliotson, in 1830, depreciates the pulse and upholds
auscultation, like the three preceding authors (Lumleyan Lectures,
p. 17 and 27). M. Bouillaud, in his treatise in 1835, (ii. p. 217,)
makes a single description of pulse answer for the whole of val-
vular diseases ! He says, closely following Corvisart, " The pulse,
irregular, unequal, and intermittent, contrasts by its smallness, its
minuteness (exiguite), with the energy, violence, and extent of the
beats of the heart: notwithstanding its smallness, it is hard and vi-
brating when the contraction is attended with great hypertrophy of
the left ventricle." Now, it is obvious that a single variety of pulse
cannot answer for every variety of valvular disease ; besides, hard-
ness and extreme minuteness are absolutely incompatible qualities !l
The mistakes of the whole of these authors have originated in
their unacquaintance with particular valvular diagnosis, whence
they mistook the pulse of one valve for that of another.
I have been endeavouring, since the year 1823, to supply the
deficiencies to which. I allude; but it is not until lately that the
subject has admitted of being brought to a satisfactory conclusion,
as discoveries on the pulse could only be consecutive to a succes-
sion of other discoveries, which, up to the present time, have gra-
dually been giving additional precision and certainty to the
diagnosis of cardiac diseases. During the last four and a half
years, I have made written notes of the pulse in 10,000 cases. The
limits of this work do not permit me to give more than the general
results of these and my previous researches.
The Pulse in Disease of the Mitral Valve. — When the mitral
valve is contracted, and also when it admits of free regurgitation,
the pulse is, in various degrees, small, weak, irregular, intermit-
tent, and unequal. When either the contraction or the regurgita-
tion is great, the whole of these characters are invariably present,
as in the cases of Dolan, Dennis, Anderson, Sharpe. But when
the degree of either is slight, (when, for instance, the circumference
of the orifice is not diminished more than an inch, or when the
aperture for regurgitation is not larger than a goose-quill,) the
effect on the pulse may only be a slight degree of weakness and
intermittence, increasing when the circulation is hurried.
The explanation of the pulses in question I conceive to be as
Yollows. In the case of contraction of the mitral orifice, the left
ventricle, not being freely supplied with blood, is not stimulated to
contract at the natural intervals, with suitable energy, and in equal
degrees. In the case of regurgitation, the ventricle, having lost
the resistance of the mitral valve, expends the force of its con-
traction in the retrograde, as well as in the forward direction, and
[' Hardness and extreme miuuteness are not incompatible; this character
of pulse is often found, for instance, in serous inflammation, especially that
of the peritoneum. — P.]
360 HOPE ON DISEASES OF THE HEART.
also expels into the aorta a diminished quantity of blood ; whence
the pulse is proportionally feeble and small : further, as the regur-
gitation disturbs the regularity of the supply to the ventricle, more
or less of intermittence, irregularity, and inequality are sooner or
later the result.
It may here be well to explain, that intermittence is the least
degree of derangement of the heart's action, as its rhythm is not
subverted, there being only the occasional omission of a beat, the
next beat recurring at the regular interval. Irregularity is an ul-
terior degree of derangement ; for, here, the rhythm is subverted,
the beats recurring at irregular intervals. Inequality almost al-
ways accompanies irregularity, some beats, both of the pulse and
heart, being stronger than others ; and I have frequently noticed a
stronger beat to be followed by one, two, or even three weaker
ventricular contractions, audible by the stethoscope, but scarcely,
and sometimes not at all, sensible in the pulse.1 When one or two
beats are regularly and permanently imperceptible in the pulse,
such cases constitute the bulk of those in which the pulse is de-
scribed by non-auscultators as being singularly slow, — for instance,
30 or 20 per minute. In a few rare cases, however, it is really
slow. I have lately seen three instances in which it was as low as
28, without any intermediate ventricular contractions. In one,
there was no disease of the heart, and the patient completely reco-
vered, hypercatharsis after fever having been the cause. I have
repeatedly seen the pulse at 40, from mere depression of the ner-
vous system.
Certain other affections, besides disease of the mitral valve, may
render the pulse small, weak, intermittent, irregular, and unequal.
These exceptions and their diagnosis must, therefore, be briefly
noticed. 1. Softening of the heart, as already shown, (p. 327)
may occasion all the above characters of the pulse in the highest
degree: it may be known by the absence of valvular murmurs.
When softening coexists with mitral disease, the two will, of course,
co-operate in producing the pulse in question. 2. The same
pulse may be produced by pericarditis with copious effusion com-
pressing the heart, by endocarditis causing polypi in the cavities
(Bouillaud), and by polypus in any other disease of the heart.
These diseases may be severally known by their own character-
istic symptoms, and by the sudden supervention of the state of
pulse. 3. Dyspepsia, nervousness, biliousness, and gout may re-
spectively occasion several, or all of the above qualities of the
pulse : they may be known by the attacks of irregularity being
only occasional and temporary, and by the absence of valvular
1 M. Bouillaud is mistaken in supposing that he was the first to notice this
species of irregularity. It was described in the first edition of this work, p.
332. He has ascribed the weaker sounds and impulses to wrong causes, as
already shown (p. 90 and 270, note).
2 Upwards of a year previous to my discovery of mitral regurgitation and
GENERAL SIGNS OF DISEASE OF THE VALVES. 361
The Pulse in contraction of the Aortic Valves. — Contraction of
the aortic valves must be very great to render the pulse small,
weak, intermittent, and irregular. I have never seen it possess
these characters in any marked degree, unless the valves were
either soldered together by cartilaginous degeneration, (case of
Hedgley,) or more or less fixed by ossification in the closed posi-
tion, so that the aperture was only a. limited chink. An induration
of the size of an ordinary pea has little effect on the fulness, firm-
ness, and regularity of the pulse, (cases of Porter and May,) and
slighter degrees of contraction appear to have no effect on it what-
ever. I have proved this by cases published in the Med. Gaz.
Sept. 1S29, and could corroborate it by a great number more. It
is obvious, indeed, that as the supply of blood to the left ventricle
is regular, its action must partake of that regularity, and that, when
the contraction of the aortic valves is not so great as to prevent the
ventricle from emptying itself, the pulse will remain full and firm.
It was respecting the pulse of aortic contraction that Corvisart
made his principal mistake ; and, as it has been copied by almost
every subsequent writer, it requires a moment's consideration.
" The pulse," says Corvisart, " may retain a certain degree of
hardness and tension, but never much of fulness or regularity.
This invariable and permanent irregularity will always be suffi-
cient to furnish a precise diagnosis of contraction of the aortic
orifice." Louis follows Corvisart (on Pericarditis, p. 12). Bouil-
laud falls into the same error in the only instance in which he
connects the pulse with the particular valve diseased. " The
pulse," says he, "is in general more irregular, small, unequal and
intermittent in simple contraction of the aortic orifice, than of the
mitral" (Traite, 1835, ii. p. 221). Now, except in the very few
cases of extreme aortic contraction, this is nothing more than the
pulse of mitral contraction or regurgitation ; for, by abstracting all
the cases of these latter affections, (which neither Corvisart, Louis,
nor Bouillaud were competent to do, because they were strangers
to particular valvular diagnosis,) 1 have ascertained in the most
positive manner that the characters of s?nallncss, and invariable,
permanent irregularity, are totally foreign to the pulse of aortic
contraction, when not extreme. If it be urged that the above
authors, though strangers to particular valvular diagnosis, could
ascertain by autopsy which was the valve diseased, in corre-
spondence with the pulse in question, a negative rejoinder may be
its pulse, in June 1825, I had noticed the pulse of mitral contraction, and
given an account of it, recorded in the Essays of the Roy. Med. Soc. of Edin.
for 1824. Mr. Hodgson, I have since found, had previously observed that, in
mitral disease, there was often a" "double pulsation of the heart," one of
which pulsations he incorrectly ascribed to the contraction of the auricles.
Since 1824, the pulse of mitral contraction has been noticed by Mr. Adams
(Dub. Hosp. Rep. iv. p. 420); Dr. Elliotson, quoting Adams; and Dr.
Hodgkin (Med. Gaz. vol. iii. p. 448), who was a fellow-student of mine in
the Edin. Infirmary and Royal Med. Soc, where he possibly imbibed the
idea.
362 HOL'E ON DISEASES OF THE HEART.
given : because, before the regurgitations were discovered, various
lesions of the auricular valves occasioning them, (e. g. mere short-
ening of the chordae, inflammatory adhesion of the posterior fold of
the valve, atrophy of the valve, &c.) were totally and habitually
overlooked.
The Pulse in regurgitation through the Aortic Valves. — Under
this head must be included regurgitation out of the aorta into the
right ventricle (Mitchell), or into the pulmonary artery (Evans).
Aortic regurgitation produces a pre-eminently jerking pulse, a
high degree of the pulse of unfilled arteries, as seen in anaemia
from any cause. The diastole or beat of the artery is short and
quick, as if the blood were smartly jerked or shot under the finger,
the vessel during the intervals feeling unusually empty. This is
the most remarkable, appreciable, and constant pulse produced by
disease of the heart. In the immense majority of cases, the practi-
tioner may conjecture the disease by this sign alone. It differs
from the jerking pulse of anaemia, in being more marked, and in
not necessarily being frequent, as the anaemic pulse is, when its
jerk is distinct. It may be absent, or scarcely appreciable, if the
regurgitation be very slight; and it may be neutralised by free
mitral regurgitation (Payne) or great contraction, in consequence
of the enfeebling effects of these lesions on the pulse.1
Valvular diseases of the right side of the heart produce little
effect on the pulse ; 1. because there is not a direct connection be-
tween that side and the arterial system ; and, 2. because the action
of the organ is less under the influence of the right ventricle than
of the left, in consequence of the superior muscular strength of the
latter. Fortunately, as valvular diseases on the right side are so
rare, we stand less in need of the evidence afforded by the pulse.
In reference to the left side, that evidence is of great value ; for it
not only substantiates the physical signs, but sometimes indicates
the degree of a valvular disease, while the physical signs merely
announce the fact. Thus, a decidedly jerking pulse denotes a free
aortic regurgitation, and a decidedly weak and irregular pulse be-
speaks great mitral contraction or free regurgitation. Nor is this
1 I described this pulse, (which had not previously been noticed by any
writer on diseases of the heart,) in several parts of the first edition of the
present work in 1831 ; especially at p. 434 ; but, having up to that time no-
ticed it solely in cases of aortic regurgitation combined with inflammation
of the heart or adhesion of the pericardium, I was in doubt as to its cause,
and ascribed it more to the latter affections than to the regurgitation, pro-
pounding, however, the question, in reference to the case of Copas, written
in 1829, whether it was not due to the regurgitation. This question I soon
after resolved in the affirmative by discovering the pulse in question in cases
of the regurgitation alone. Dr. Corrigan, who wrote in 1832 or 1833 on
permanent patency of the aortic valves as a supposed new disease, has so
completely overlooked this pulse as even to state the reverse: "it rises
without any jerk under the finger" (Dublin Jour. vol. x. p. 186). M. Donne
subsequently wrote a thesis on aortic regurgitation, which I have not been
able to procure : but as M. Bouillaud, who quotes him, does not anywhere
allude to the jerking pulse, I presume that it was overlooked by M. Donne
also.
TERMINATIONS OF DISEASE OF THE VALVES. 363
knowledge a mere diagnostic refinement. It is of practical value ;
since a latitude may be permitted to the patient in slight degrees
of the disease, which would be totally inadmissible in the more
advranced.
c. Pain in the region of the heart is another symptom that
affords presumptions of disease of the valves. It is true that
palpitation or engorgement of the heart may occasion pain, though
there be no disease of the valves: I have frequently met with it
from these causes in hypertrophy and dilatation. It is likewise
true that palpitation may occasion pain, though there be no disease
of the heart whatever ; I have found it in a large proportion of
hysterical, anaemic females and nervous males. But it is when the
valves, the coronary arteries, or the commencement of the aorta, are
indurated and inelastic, that pain occurs most frequently and with
the greatest severity. Sometimes it is little more than an inde-
scribable sense of obstruction or oppression in the prsecordial re-
gion ; but, in other cases, it is an intense lancinating or tearing
pain, felt across the praccordia or scrobiculus cordis (where it might
be mistaken for inflammation of the stomach,) and occasionally
extending, with a sense of numbness, down the inside of the left
arm to the elbow, and sometimes to the fingers. Pain of this de-
scription has acquired the name of angina pectoris. (See Angina
Pectoris.)
I believe this pain to be, in general, occasioned by the inelasticity
of the ossified or otherwise indurated parts, which wi.l not stretch
equally with the other portions of the heart, when the organ is
labouring under palpitation or engorgement. When inflammation
of the interior of the heart exists, it also may occasion pain ; but
those authors have unquestionably been wrong who have considered
inflammation to be the sole cause of pain, and have therefore
assumed this symptom as proof of the inflammatory nature of
disease of the valves. The truth is. that the pain of acute endo-
carditis is neither of common occurrence, nor considerable in degree.
Progress, terminations and prognosis. — The exact time and
manner of the fatal termination in valvular disease, as in every
other organic affection of the heart, is very uncertain. Sometimes
the patient is reduced gradually to an extreme degree of emaciation
and debility, and dissolution is duly announced by the usual pre-
monitory symptoms. Sometimes he expires suddenly, after any
exertion or emotion, though the malady have made comparatively
little inroad on the constitution. In this case the event must be
attributed to the obstruction having attained, by the progress of the
disease, such a point that the heart, when hurried beyond a certain
degree, can no longer maintain the circulation against it. Not
unfrequently, pressure on the brain, whether from venous conges-
tion, or its consequence serous effusion, is the immediate cause of
death, and in this case coma usually supervenes gradually, in the
course of from three to four days or a week previous to the fatal
event (Dolan). It may, however, occur abruptly. In one case.
364 HOPE ON DISEASES OF THE HEART.
under my care, of serous effusion, the patient suddenly uttered a
shriek and fell at once into perfect coma; and I have seen many
cases of sudden apoplexy, both congestive and hemorrhagic.
Hence, the prognosis must always be general as to time, and, if
the case be considerably advanced, it must be guarded with a clause,
that the patient is liable to die suddenly and unexpectedly. This
catastrophe, however, is much more rare since the improved dia-
gnosis of the diseases of the heart has made it possible to enjoin
suitable precautions.
Physical Signs. — Before the discovery of auscultation, it was
extremely difficult, and in many cases utterly impossible, to detect
disease of the valves. Corvisart had the merit of discovering, as its
signs, certain states of the pulse, and a "peculiar vibration difficult
to describe, sensible to the hand applied to the prascordial region :" —
in other words the cat's purring tremour (/remiss ement cataire) of
M. Laennec. But, as these signs may occur under other circum-
stances, they do not denote disease of the valves in particular, and
are totally insufficient to indicate which is the valve affected. The
accession of auscultation to the other means of diagnosis, has ren-
dered it possible to distinguish valvular disease, both in general and
in particular, with almost complete certainty : a certainty, it maybe
remarked, much greater than was supposed by the illustrious author
of auscultation himself; for he did not give their full value to
preternatural murmurs as signs of disease of the valves, in conse-
quence of supposing that similar murmurs were produced by
spasmodic contraction of the muscular fibre of the heart and even of
the arteries, and in consequence of being unacquainted with the
whole class of murmurs from regurgitation subsequently discovered
by the writer. Thus he says, " The anomalies in the sounds of the
heart and arteries of which I am going to speak (viz. bruit de soufflet
and fremissement cataire) are the more remarkable, because, of
all those which auscultation has revealed, they alone are not con-
nected with any organic lesion in which we can find their cause, "
and again, "It appears to me that the positive and negative facts
which I have just advanced, all tend to prove that bruit de sovfflet
is the product of a simple spasm, and does not suppose any organic
lesion in the heart and arteries" I have shown, at p. 118 etseq.,
that it is not spasm of any kind, but a modified movement of the
blood, attended with increased friction and vibration, which is, in
all circumstances, the cause of inorganic murmurs and tremours,
whether in the heart, the arteries, or the veins, and whether ordinary,
continuous, humming, or whistling. Independent of these, there are
no murmurs and tremours which may not be distinctly traced to
organic causes. Laennec laboured under another disadvantage:
he attributed the second sound of the heart to the auricular contrac-
tion ; whereas, it is demonstrated by the experiments of the writer
that the auricles yield no sound,1 (p. 47) and that the second sound
[ l Drs. Pennock and Moore's experiments, subsequently instituted, prove
the existence of an auricular sound. The fact of the first sound being " princi-
pally valvular," as stated above, is very questionable. Vide Experiments. — P.]
PHYSICAL SIGNS OF DISEASE OF THE VALVES. 365
is referable to the closure of the semilunar valves (p. 79) : also,
that the first sound, instead of being wholly muscular, as he ima-
gined, is partly muscular, but principally valvular (p. 79). These
errors necessarily perplexed him in referring murmurs to their true
source.
Having, in the section on murmurs from valvular disease, (p.
105 et seq.,) fully considered the nature, causes and mechanism of
the bellows, filing, saicing, rasping, and musical or whistling
murmurs; having pointed out the situations where they are to be
explored, (p. 114) and having in the section on purring tremour or
thrill, (p. 141,) presented a synoptical sketch of this associtaed
phenomenon ; 1 now proceed to show in what manner they con-
stitute signs of disease of each of the valves in particular. It may
be premised that, as the sounds of one side of the heart are audible
on the other, the sound of the healthy side will partake some-
what of the murmur of the diseased side ; yet not so as to create a
fallacy, if due attention be paid to the diagnostic rules which will
now be offered.
["In judging of the seat and cause of a cardiac murmur, you have to
attend chiefly to the period of the heart's motions at which it occurs, and the
manner in which it is transmitted to the surface. A murmur accompanying
only the first sound or impulse is necessarily caused by a current of blood
from a ventricle; one accompanying, following or replacing the second
sound, must arise from a current into a ventricle. This simplifies the
matter; but there are still two ventricles and two orifices to each; and how
are the murmurs of these respectively to be distinguished ? not by the
different position of these orifices certainly ; they are too close together for
that; but by the different directions in which the sonorous currents spread
the sounds, and the different manner in which they are transmitted to the
walls of the chest. Thus murmurs generated at the origin of the arteries
will generally be more or less transmitted in the direction of the current
along these arteries; and those produced in the auricular orifices will be
conducted both by the current into the auricles, and by the tightened cords
and fleshy columns to the apex of the heart, which is generally more or less
in contact with the ribs.'-* — Williams, op. citat. — P.]
Signs of Disease of the Aortic Valves} — One of the murmurs
above alluded to is heard during the ventricular contraction, (i. e.
with the first sound,) on the sternum, opposite to the lower margin
of the third rib, and thence for about two inches or more upwards,
along- the course of the ascending aorta towards the right; and it
is louder in these situations than below the level of the valves. Its
pitch or key is usually that of a whispered r, from being superficial,
and it accordingly conveys the idea of being pretty near to the ear.
When a murmur of this kind is considerably louder along the tract
of the ascending aorta than opposite to its valves, and is, at the
same time, unusually near-sounding and superficial— in other
words, on a higher key than a whispered r, it proceeds from disease
of the ascending aorta itself. As the murmur from this cause is
1 The young student is strongly recommended to copy the diagrams Fig.
4, and carry them about with him in his pocket, till he is thoroughly master
of this subject.
366
HOPE ON DISEASES OF THE HEART.
audible in the situation of the valves, it might lead to the supposi-
tion that they also were diseased, and it is sometimes very difficult
to ascertain positively that they are not. That a murmur is seated
in the aorta, and not in the pulmonary artery, may be known by its
being inaudible or very indistinct high up the course of the pulmo-
nary artery, while it is distinct high up that of the aorta. That a
murmur is seated in the aorta or its valves, and not in the auricular
valves, may be known by its sounding loud and near above the
aortic valves, where an auricular murmur, if audible at all, sounds
feeble, remote^ and on a low key, like a whispered who.
[" Obstructive disease of the aortic orifice (observe, by obstructive I do nol
mean that the actual impediment is always much,) is generally attended by
a murmur with the first sound and impulse, heard in the region of the heart,
along the upper half of the sternum, and in the right or both carotid arteries.
The point where it is heard loudest will vary according to the position of the
heart with regard to the lungs and walls of the chest. If it lie deep, and
well covered with spongy lung, the murmur may be louder at the apex and
in the right carotid than at any intermediate point, because the dense heart
and the distended arteries convey the sound better than even a much shorter
length of pulmonary tissue. Tn chests less deep, and especially when
enlargement of the heart bring its base nearer to the sternum, the sound is
loudest about the middle of this bone, or a little on either side of it ; but still
the more distinguishing character is, that it is heard above, in the direction
of the innominata and carotid arteries, where sounds from the other valves
can scarcely reach. The murmur is commonly like grating or sawing, and
varies much in length and loudness in different cases. In some it lasts the
whole period from the commencement of the systole to the occurrence of the
second sound : in others it is a mere roughness or whizzing accompanying
the natural sound, which may be pronounced trrhub-dup or djub-dup. It is
very often accompanied by regurgitant disease of the aortic valves; and
when this is not the case, the second sound (the dup) is frequently less
clear than usual, which implies that the valves, from thickening, do not act
freely."— C. J. B. Williams.— P.]
When there is regurgitation through the permanently open aortic
valves, a murmur accompanies the second sound, and its source
may be known by the following circumstances: — 1. It is louder
and more superficial opposite to and above the aortic valves than
about the apex of the heart, by which it is distinguished from a
murmur in the auricular valves with the second sound. 2. It is
louder along the course of the ascending aorta than along that of
the pulmonary artery, and down the tract of the left ventricle than
down that of the right; by which circumstances its seat is known
to be in the aortic, and not in the pulmonic valves. This inference
is strongly corroborated by the state of the pulse, which, when the
aortic regurgitation is at all considerable, is singularly and pre-
eminently jerking — the pulse of unfilled arteries. 3. It is distin-
guished from a systollic murmur in the aortic orifice by its accom-
panying the second sound ; by its being more audible, (though
with a gradual diminution,) down the course of the ventricle, than
a systolic murmur ; by its being prolonged through the whole
interval of repose, and even through accidental intermissions of
the ventricular contraction (case of W. Esq.) ; and by the weakness
PHYSICAL SIGNS OF DISEASE OF THE VALVES. 367
of the refluent current always imparting to it the softness of
the bellows-murmur, an inferior degree of loudness, and a lower
key, like whispering the word awe during inspiration. It often
becomes musical.
[The duration of the murmur in the second sound produced by the regur-
gitation of blood through the aortic orifice, will depend upon the facility of
closure of the aortic semilunar valves. If the obstructive disease be slight,
so that the valves soon close by the recoil of the arterial column upon them,
but a slight jet of blood will pass between their edges. The murmur there-
by produced is represented by Williams, by the articulate symbol of trrht,
or, tzzt, (instead of dup). Should the valve remain permanently open, the
abnormal sound from regurgitation, instead of being of short duration, may
continue during the whole period of the diastole. — P.]
Purring tremor, though necessarily produced by any considerable,
salient, or rugged contraction of the aortic valves, can rarely be felt,
because the sternum is interposed; but when the heart is displaced
from beneath the sternum, as by hydrothorax, empyema, emphy-
sema, tumours, consolidation and contraction of one lung and
hypertrophy of the other (case of James), (fee. the tremor may then
become perceptible (case of Mitchell). I have never known it
accompany aortic regurgitation.1 Probably the refluent current is
too feeble to render it perceptible through the walls of the chest.
Aortic regurgitation, however, by unfilling the arteries, eminently
favours the production of tremor from contraction of the aortic
valves, during the ventricular systole (see p. 142).
Irregularity of the pulse is not necessarily or usually produced
by contraction of the aortic valves, unless extreme (e. g. case of
Hedgley) ; nor are the size and strength of the pulse materially
diminished by moderate contraction. Aortic regurgitation produces
the eminently jerking pulse; and this it does whether the regurgi-
tation be into the left ventricle, or through a false opening into the
pulmonary artery or mouth of the right ventricle (Mitchell and
Evans).2
[" Combined obstructive and regurgitant lesions of the aortic orifice pro-
duce the double, or to-and-fro sawing murmur, which is the succession of
the forward and backward gushes of blood. They are by no means uncom-
mon ; in fact, the murmur, instead of the second sound, indicating regurgi-
tation, seldom exists withouta murmur with the first also, indicating partial
obstruction. These lesions, when at all considerable, are accompanied by
dilated hypertrophy of the left ventricle, which often takes an elongated
form, bringing its impulse lower and more to the left than usual. When
the regurgitation is very free, it increases the force of the diastolic collapse
so much, that I have known it resemble a second impulse. It also not un-
1 It did not exist even in a case of displacement which I lately examined,
where the aorta beat between the second and third ribs, an inch to the right
of the sternum.
2 While I was writing the above, a physician brought to me his son,
affected with aortic regurgitation, who, he said, had what a friend called a
i: quick, slow pulse." The epithet is quaintly expressive. It is rendered in
Latin by celer ct infrequens ; whereas the jerking pulse of anaemia is celer
et frequens.
368 HOPE ON DISEASES OF THE HEART.
frequently stimulates the ventricle to a second contraction, constituting a
reduplication of the pulse ; the rhythm otherwise is not commonly much af-
fected. But the pulse generally possesses a character that is remarkable.
When the lesion is obstructive only, the pulse is generally hard and jarring ;
but when it is regurgitant also, each pulse, although momentarily hard and
full, immediately recedes, which gives it a jerking or thrilling character.
The same circumstance makes the pulsation of all the arteries visible, and
sometimes locomotive, — a sign of lesions of the aortic valves first pointed
out by Dr. Corrigan. I have seen it so extensive in an old man, that many
arteries could be seen like worms under the skin, wriggling into tortuous
lines at each pulse. The cause of this phenomenon is sufficiently intelli-
gible. It proceeds from a defective equality of tension of the arterial coats.
These vessels are distended at each pulse, and emptied the instant after,
the aortic valves not, as usual, maintaining their tension ; and if the coats
of the arteries are defective in lateral elasticity, as in old people, they may
admit each jerking jet of blood only by being elongated into a tortuous line.
In its extreme degrees, and especially when existing in all states of the cir-
culation, I think that this visible or moving pulsation of the arteries is
pathognomonic of regurgitant disease of the aortic valves; but to a slight
extent it may be observed in many cases of excited action of the heart, espe-
cially when there is a defective tension of the arteries, as after great losses of
blood, and otherwise where there is a bad state of the vascular system. I
should have pointed out to you a partial exhibition of this visible pulse as a
sign of such a state of the arterial system. By raising the hand above the
rest of the body, you will render visible the pulsations of the radial artery,
which becomes partially emptied by gravitation, just as in case of aortic
valvular disease the arteries in general become partially collapsed by regur-
gitation."— Williams^s Lectures. — P.]
[The general symptoms of disease of the aortic valves vary in intensity
according to the extent of the lesion, and pathological condition of the heart.
As has been previously mentioned, a slight lesion of the aortic valves may
exist for some time, and if not complicated by a dilated or hypertrophied
state of the heart may cause but little inconvenience to the patient. Such
uncomplicated cases are marked by some palpitation or shortness of breath
on exertion, which, if carried to some extent, gives rise to a sense of tightness
or pain at the sternum. But when the disease is extensive, it is almost
always connected either with dilatation or hypertrophy, or both conjoined,
and causes symptoms of the most distressing kind. The dyspnoea and in-
creased action of the heart then become habitual, which when aggravated
cause fits of palpitation or even orthopncea, extreme jactitation, inability to
maintain the horizontal posture, attended by cough, asthma, &c. Anasarca,
commencing in the extremities, is a very common accompaniment of this
form of disease, and is more frequently seen than ascites or hydrothorax.
When the ventricular parietes of the heart have become hypertrophied and
dilated, other symptoms similar to those arising from regurgitant mitral
disease are superadded ; these will be detailed in their proper place. A
peculiar pallidity, or pastiness of the complexion, with puffiness of the face
is often seen. — P]
Signs of Disease of (he Pulmonic Valves. — The signs of con-
traction of the pulmonic valves are the same as those of the aortic,
(p. 365,) with this difference ; that, from the vessel being nearer
the surface the murmur with the first sound seems closer to the ear,
and is on a higher key, ranging from the sound of a whispered r
towards that of s. I have, however, known it fall below r when
the circulation was feeble and slow, and the obstruction slight. It
may be known that the murmur is not seated in the aorta, by its
PHYSICAL SIGNS OF DISEASE OF THE VALVES. 369
being- inaudible, or comparatively feeble, two inches up that vessel ;
whereas, at a corresponding height up the pulmonary artery, it is
distinct : also, by its being louder down the tract of the right ven-
tricle than down that of the left (Bowden). It may be known that
the murmur does not proceed from regurgitation through the auri-
cular valves, by its being distinct along the'course of the pulmonary
artery, where auricular murmurs are either wholly inaudible, or
very feeble and remote.
When a murmur in the pulmonary artery is considerably louder
between the second and third left ribs, close to the sternum, than
opposite to the valves, and is there attended with impulse and pur-
ring tremor, dilatation of the pulmonary artery may be suspected
(see Dilatation of Pulmonary Artery). In one instance I have
known a murmur to be produced by complete ossification of the pul-
monary artery penetrating deeply into the lungs (case of Lady JR.).
When there is regurgitation through the pulmonic valves, a
murmur accompanies the second sound. Its nature and diagnosis
are the same, (the necessary inversions being made,) as in the case
of aortic regurgitation, (p. 366,) except that the pulse is not jerking
(case of Rogers. A tremor attended).
I presume that purring tremor with the first sound may be occa-
sioned by contraction of the pulmonic orifice, though I have not
met with an instance verified after death : but I have met with
three in which the tremor attended dilatation of the pulmonary
artery (Weatherly, Bowden, and Miss L. P r). A purring
tremor occasioned by the pulmonic valves would be more readily
felt than one occasioned by the aortic valves, because it would
probably be transmitted as far as the space between the second and
third ribs, (where it is out of the cover of the sternum,) provided
the patient lay in the horizontal position, and inclined to the left
side.
Disease of the pulmonic valves is so rare, that it ought never to
be suspected unless the signs described are perfectly well marked,
or unless there be patescence of the foramen ovale, or some other
communication between the two sides of the heart, — states which
experience has proved to be generally accompanied with contrac-
tion of the orifice in question.
Signs of Disease of the Mitral Valve. — When the valve is
permanently open, admitting of regurgitation, the first sound is at-
tended with a murmur. It may be rough, (rasping,) or smooth,
(bellows-murmur.) according to the nature of the contraction, [the
force of the circulation and the character of the blood,] &c. (p. 107).
Its key is low, — more or less like whispering who (p. 110); yet it
sounds loud and near if explored about the apex of the heart, and
a little to the sternal side of the nipple.1 It may thus be easily
1 The reader is particularly requested to refer to Figs. 2 and 3, where he
will distinctly see the principle on which the sounds, both natural and
morbid, of the auricular valves are transmitted to the apex of the heart,
rather than to the anterior walls, opposite to the auricular orifices.
11— e 24 hope
370 HOPE ON DISEASES OF THE HEART.
distinguished from a direct semilunar murmur, which, in this low-
situation, always sounds feeble and distant. The murmur in
some cases completely drowns the natural first sound on the left
side : in others, the sound can be distinguished at the commence-
ment of the murmur.1
I have found perceptible purring tremor to be produced more
frequently by regurgitation through the mitral valve than by any
other valvular lesion — especially when the ventricle was hyper-
trophous and dilated, by which the refluent current was rendered
stronger.
If the regurgitation be considerable, but not otherwise, the pulse
is more or less small, weak, intermittent, irregular and unequal
(p. 359) ; and this, even though the impulse of the heart be violent.
When the mitral valve is considerably contracted, a murmur
(best heard in the same situation as the murmur from regurgita-
tion, and distinguishable in the same way from semilunar mur-
murs,) attends the ventricular diastole and second sound. From
the weakness, however, of the diastolic current out of the auricle,
the murmur is always very feeble, soft like the bellows-sound, and
usually on a rather lower key than a whispered who (p. 110). I
have found this murmur absent unless the contraction of the valve
was considerable ; for the blood had still sufficient room to pass
with tranquillity : and I have also found it absent when the contrac-
tion was great — when, for instance, the aperture admitted one finger
only, or merely a quill, provided the current was preternaturally
weakened by softening, by extreme dilatation of the heart, or by
both (cases of Anderson and Mrs. 1 — n). In such cases, how-
ever, the mitral disease would not be overlooked, as there is almost
invariably a murmur from regurgitation. On the whole, this mur-
mur is exceedingly rare, though Laennec and authors in general
have supposed quite the contrary, from mistaking for it the murmur
of aortic regurgitation (see p. 103).
I have never known purring tremor accompany a diastolic mitral
murmur, the current being too feeble to produce it.
When the contraction of the mitral valve is great, the pulse
(whether there be regurgitation or not) is more or less small, weak,
intermittent, irregular and unequal, in consequence of the supply
of blood to the left ventricle being insufficient and irregular (p. 359.)
I have known the same to be occasioned by a polypus choking up
the left auricle.
[_" Regurgitant lesions of the mitral valve are attended by a murmur with
the impulse and first sound, produced by a sonorous jet of blood through the
1 The natural sound must not be confounded with the accidental sound of
costal percussion, and metallic tinnitus, produced, -as I have shown, (p. 73,)
by the apex of the heart impinging against the lower edge of the fifth rib, as
it glides up during the systole ; and occurring in emaciated, anaemic subjects
during palpitation. Thus, in the case of Jones, a murmur superseded the
natural first sound ; but, during palpitation, the sound of costal percussion
became loudly perceptible.
PHYSICAL SIGNS OF DISEASE OF THE VALVES. 371
imperfectly closed valve at each systole. I have more than once adverted
to the nicely-adjusted mechanism of this valve, and I have given you a suffi-
cient number of examples of the lesions by which this mechanism may be
deranged. They are very common ; and my experience leads me to the
conclusion, that of the instances of cardiac murmurs which present them-
selves in women and young persons below the age of twenty, five sixths are
caused by regurgitant disease of the mitral valves ; whilst in older persons,
and those of the other sex, they are more frequently caused by disease of the
aortic orifice. Now where may this murmur be best heard ? The mitral
valve is situated about the cartilage of the fourth left rib, near the sternum ;
but the spongy lung, and the right ventricle, too, if it be dilated, intervenes
between it and the walls of the chest ; hence the murmur is seldom trans-
mitted opposite to the valve so well as through the apex, to which the fleshy-
columns of the valves are attached, and wThich, at the time that the murmur
is produced, is in close contact with the walls of the chest, somewhere be-
tween the fourth and seventh ribs below, or a little in front of the left mam-
milla. Here, accordingly, I have generally found mitral murmurs most
distinct, being often quite superficial, and so loud as to eclipse the natural
double sound ; and this being still audible at the upper and lower ends and
to the right of the sternum, and in the carotid arteries, where ihe murmur is
inaudible or distant, completes the diagnosis. Great enlargement of the
heart, or consolidation of the lung, sometimes transmits the murmur loud to
the walls higher up, in which case the dulness on percussion at the spot
would explain the unusual circumstance. In a few instances I have heard
a mitral murmur very loud and superficial about the third rib near the mam-
milla, and I have been led to suspect that it is in these cases transmitted by
the dilated auricle which receives the refluent jet of blood. It is sometimes
very audible in the left back, and below the axilla. The character of mitral
murmurs is generally blowing, but sometimes passing into a whistle, and
more rarely grating. In some cases it accompanies the whole systolic act,
and terminates with the second sound : in others it is confined to the end of
the first sound, giving to it an additional vowel or roughness, as we may
express by the words loo-dup or lurrdup ; or, if confined to the beginning,
rehub-dttp or jub-dup. You may be amused at my new words; but I think
that when your ears shall have become practised, you will admit I have
spoken truly the language of Ike heart. These murmurs are not always
constant, especially when the action of the heart is irregular or unequal.
We then often hear some of the beats with the murmur, and others without
it. Sometimes the murmur alternates with a double first sound, which I
have compared to the footsteps of a cantering horse, and which I have con-
jectured to depend on a loose state of part of the mitral valve. When you
once understand the principles of the production of these sounds, such varie-
ties are intelligible enough.
'•As there is in most cases of considerable disease of the mitral valve
more or less hypertrophy and dilatation of the heart, the signs of these con-
ditions may be added to those of the valvular lesion. But if the regurgita-
tion is free, it may much diminish the loud sound of dilatation, and the
strong impulse of hypertrophy of the left ventricle, by removing the resist-
ance offered by the closure of the mitral valve. Hence the tightening flap
of the ventricular sound may be diminished as well as disguised by the
murmur ; and the strength of the impulse may be partially lost backwards
into the auricle, and followed by a heavy diastolic collapse, when the blood
flows in again from the distended auricle. When there is contraction of the
mitral orifice, there is usually more hypertrophy than dilatation in the left
ventricle, with a strong impulse over it, and the blowing of regurgitation,
which is scarcely ever absent, even in these cases. The other compart-
ments are dilated, and may give, as usual, the short double sound." — C. J.
B. Williams.—?.]
24*
372 HOPE ON DISEASES OF THE HEART.
[General Symptoms of Disease of the Mitral Valves. — When the lesion
is confined entirely to the mitral valves, the patient suffers but slight incon-
venience, and the principal sign of disease will then be the irregularities of
the pulse, occasional shortness of breath, and the regurgitant murmur heard
near the apex. But the affection is progressive ; the right ventricle, in con-
sequence of the left divisions of the heart being surcharged with blood, be-
comes distended, and the different viscera are affected through the circulation ;
for a portion of blood, sent through the veins, being constantly forced back-
wards by each beat of the heart, produces "an accumulative effect" upon the
different internal organs. Hence the derangement of the hepatic and abdo-
minal functions are extremely frequent, even in the earlier stages of this
disease, and bilious and dyspeptic symptoms entirely mask the primitive
affection. The lungs, suffering from engorgements, dyspnoea takes place,
together with asthmatic symptoms, or the patient is harassed by distressing
cough, signs of pulmonary apoplexy, with expectoration of blood or bloody
sputa, or copious thin mucus, frequently tinged with blood. Along with
these symptoms, others, arising from a congested state of the venous sys-
tem, may be presented, such as hemorrhoids, disease of the kidneys, ascites,
anasarca, congestive headaches, giddiness, &c.
In the worst forms of mitral disease, pulmonary and venous congestions
are presented together; — in these cases with irregular and inordinate action
of the heart, are superadded all the symptoms previously mentioned, and we
then have presented a disease which is most truly terrible. — P.]
Signs of Disease of the Tricuspid Valve. — They are the same
as those of the mitral, except that the murmurs are loudest on or
near the sternum, at the same level as in the case of the mitral —
namely, about or a little above where the apex beats; and except,
also, that the pulse is little affected with irregularity. 1 have never
known purring tremor produced by this valve.
As the tricuspid valve is very rarely so much diseased as to
yield a murmur, its lesions being exceedingly unfrequent and almost
always in a slight degree, the practitioner must be very cautious in
pronouncing it diseased, especially as the pulse does not afford the
same evidence as in contraction of the mitral orifice.
Signs of Disease of the Arterial and Auricular Valves con-
jointly.— The murmurs above described as characteristic of each,
exist simultaneously in both. The auscultator has merely to take
especial care that he explores the arterial murmurs as high up the
vessels, and the auricular murmurs as low down the heart, as pos-
sible. He will thus readily satisfy himself that there are two dis-
tinct sources of murmur. It is still easier to determine this, if the
murmur attending either sound be of a different species in the two
situations — if, for instance, the murmur of the aortic or pulmonic
valves be of the soft bellows-kind, while that of the auricular valve
is of the rough, grating or rasping kind, or vice versa.
Diagnosis of Valvular from Inorganic Murmurs. — To make
the above signs completely available, it is necessary to attend to
several circumstances which might lead to" deception. Bellows-
murmur, as already fully explained, (p. 120,) sometimes exists in the
heart, though there be no disease of the valves : namely, in anaemic
persons, who, at the same time, are generally nervous and excitable
(p. 124); in excessive hemorrhage and the reaction following it,
PHYSICAL SIGNS OF DISEASE OF THE VALVES. 373
where anaemia is still the essential cause (p. 121) ; and in a very
few cases of hypertrophy with dilatation, where again the pheno-
menon is principally ansemic (p. 117). Murmur from these causes
may easily be distinguished from that of valvular disease by the fol-
lowing criteria.
1. It is confined to the aortic orifice, (so far as I have yet disco-
vered,) and to the first sound. Here is one of the great advantages
of particular valvular diagnosis, as the auscultator can at once ex-
clude the other seven murmurs to which the heart is liable from
organic causes only.
[The assertion of the author, that the murmur in question is confined to
the aortic orifice, is too general. I have repeatedly observed it over the apex
of the heart when it was not found upon the sternum, at or above the third
ribs; thus proving that it was generated at the mitral orifice, and not at the
aortic. — P.]
2. It is always iveak, and of the soft or bellows kind.
3. In the anaemic, it is almost invariably attended with a con-
tinuous venous murmur in the jugulars, and mostly with a short
bellows-whiff, in the carotids, subclavians, and other principal
arteries, synchronous with the first sound of the heart.
4. It exists in the anaemic [and irritable, — P.] during temporary
excitement of the circulation only, subsiding when palpitation ceases
and the pulse falls to its natural standard ; but as the pulse is
permanently quick in considerable anaemia affecting irritable,
nervous subjects, especially females ; also during the period of reac-
tion after excessive loss of blood, the murmur will persist until the
pulse falls by the subsidence of the states in question.
5. The murmur, both of the heart, arteries, and veins, wholly
ceases when the anaemia is cured by iron and animal food, the venous
murmur being the last that becomes extinct.
When a murmur proceeds from hypertrophy with dilatation it
may be known by its diminishing or ceasing when the action of the
heart is calmed, as by repose, venesection, digitalis, &c. In most, if
not all cases, this murmur is dependent merely on anaemia, which
is very apt to supervene in the advanced stages of hypertrophy
with dilatation.
Contrasted with the above, the distinctive characters of valvular
murmurs are, 1. That they are not, like inorganic murmurs, restrict-
ed to the aortic orifice and first sound, but may be connected with any
of the four orifices and with either sound in each : 2. That they
persist without intermission for an indefinite length of time, even
though the heart be kept in a state of perfect calm : 3. That they
are often of a rough character, that is, filing or rasping ; whereas, in-
organic murmurs have always the softness of the bellows-sound.
Such are the signs which, together with the general symptoms,
are. according to my experience, the best for the detection of the
diseases of the valves. In the first edition of this work, where the
signs were less fully developed, I was enabled to say that "for
several years they had never deceived me as to the general fact
374 HOPE ON DISEASES OF THE HEART.
whether there was or was not valvular obstruction, and that they
had seldom failed to indicate, with perhaps more than necessary pre-
cision, the situation of the affection." I may now venture to add,
that, with the improvements introduced in the present edition, the
particular diagnosis is even more easy and certain than the general ;
because a practitioner competent to make the latter only, is more
liable to be deceived by inorganic murmurs. I have no doubt that,
ere long, the physical signs in particular will be universally ad-
mitted to be as simple and easy as I represent them to be, since I
have found by trials that intelligent students are competent to
make particular diagnosis after a verbal explanation not exceeding
a quarter of an hour's duration. I feel assured also that valvular
diagnosis will shortly be acknowledged to be more certain than that
of the muscular diseases of the heart, because the physical signs of
valvular disease are more fixed.
If it be said that particular valvular diagnosis is a useless refine-
ment, it may be replied that non-auscultators used to say the same of
auscultation in general. The truth is, that every improvement in
diagnosis is an advantage to the practice of medicine. No one, for
instance, will deny the importance of distinguishing inorganic from
organic murmurs, as the treatment for the two is diametrically oppo-
site ; and this distinction, it has been shown, is remarkably facilitated
by particular valvular diagnosis. A^ain, the pulse, without parti-
cular diagnosis, is unintelligible even to the most learned, as Corvi-
sart, Laennec, &c, and has betrayed them into grievous practical
errors. Further, disease of certain valves is more injurious and
dangerous than that of others. Unless, therefore, the practitioner is
able to specify the valve diseased, he cannot nicely adapt his treat-
ment to the exigencies of the case, but must in some instances be
uselessly rigid, and in others dangerously lax.1
As an appendix to the present subject, I may advert to a few
unusual and curious sources of murmur independent of valvular
disease, which constitute the only remaining causes of fallacy with
which I am acquainted.
1 1t is astonishing that a writer who has had so much experience as M. Bouil-
laud, does not even pretend to particular valvular diagnosis as late as the year
1835. The following is his summary of signs : ''To sum up, when we hear
in a patient a permanent bellows, rasping, or sawing murmur in the precordial
region, when there is at the same time a vibratory tremor and palpitations, or
tumultous, irregular, intermittent beats of the heart, it is almost certain, if the
disease is already of several months or years standing, that there is an indura-
tion of the valves with contraction of one or several orifices of the heart. No-
thing is wanting to the certainty of the diagnosis when, to these local signs
accede the signs called general, and which are the result of the influence exer-
cised on the functions of the other organs by the obstacle to the passage of the
blood through the heart" (Traite, ii. p. 216). Most assuredly, no one could
mistake a valvular disease which presented all these signs; but the great ma-
jority do not present half of them ! What is to be done then ? It is no
wonder that valvular diagnosis was difficult while the signs were so complex
vague, and general, as M. Bouillaud makes them.
PHYSICAL SIGNS OF DISEASE OF THE VALVES. 375
1. I had a patient in the St. Mary-le-bone Infirmary, in whom I,
as well as the apothecary Mr. Hutchinson, noticed a distinct murmur
along the ascending aorta on some occasions, and not the slightest
on others. I was much perplexed, and could not make up my mind
as to the existence of valvular or aortic disease. The patient died
of phthisis, and on post-mortem examination, it was found that the
anterior edge of the left lung, completely indurated by tubercular
deposition, pressed so exactly on the ascending aorta as actually to
have taken its mould, though without adhering. It was now recol-
lected that the murmur had always been heard when she lay on her
back or inclined to the right side, but not when inclined to the left :
hence we ascribed it to pressure of the lung on the aorta when the
position of the body caused it to gravitate towards the right side.
2. Two students of University College called on me, one with
slight hypertrophy with dilatation, and violent palpitation from great
nervous excitability, — the pulse, for instance, being 120; the other
was exempt from organic disease, but affected with violent nervous
palpitation, the pulse here also being 120. Both wore very tight
waistcoats, preventing the expansion of the lower ribs. During
this state of breathing, with the lungs insufficiently inflated, a slight
bellows-murmur with the first sound over the semilunar valves
existed in both. It was not, however, exactly synchronous with
that sound, but began an instant later, as if from a separate cause.
In both, the murmur ceased entirely when, unbuttoning their waist-
coats and waistbands of their trowsers, they breathed with the lungs
naturally inflated. By alternating the circumstances, the murmur
could be created or removed at pleasure. I presume, therefore, that
it proceeded from a cause exterior to the heart ; and, as the mur-
mur was an instant later than the first sound, the most probable
appears to be, that, in the contracted state of the chest, the violent
beats of the heart compressed the lung, and, by suddenly expelling
its air, created a murmur.
-3. Dr. Elliotson mentions two or three cases somewhat analo-
gous. In one — a case of ascites — a bellows-murmur with the first
sound, in the region of the left ventricle, instantly ceased on the
removal of the fluid from the abdomen ; but when it re-accumu-
lated, the sound again became audible. In another case — a young
woman with chronic bronchitis, dyspnoea, livid lips and cedematous
legs — no murmur existed while she was erect, but it became audible
the moment she lay down (Lum. Lees. p. IS). Dr. Elliotson con-
jectures that, in the first case, the elevation of the heart by the
abdominal fluid might have tilted the organ to an angle with the
commencement of the aorta : and, in the second case, he thinks that
the cessation of the murmur when the patient was erect, depended
on the ventricle beins", by gravitation, drawn down more into a
straight line with the aorta, when an easier exit was given to the
blood. Another conjecture in which he indulges, but to which I
cannot assent, is, that dilatation of the right auricle, by pressing
against the aorta, -night have occasioned the murmur in both.
376 HOPE ON DISEASES OP THE HEART.
I have not data by which to decide these points, but the practical
inference is, that, in cases of slight bellows-murmur with the first
sound, and connected with the arterial orifices, (for the fallacy can-
not apply under any other circumstances,) we should not decide
till we have ascertained that the murmur continues in the erect as
well as the recumbent position, and also while the chest is totally
unrestrained by ligatures. I have at present a case of an exceed-
ingly anaemic girl, ast. 17, in whom a venous murmur in the vena
innominata was propagated down the great vessels, especially the
pulmonary artery, and led a young auscultator into the error of
supposing that there was disease of the pulmonic valves.
In conclusion, these anomalous cases are very rare ; and they
will create little difficulty, if due attention be paid to the rules laid
down respecting the best situations in which to explore the mur-
murs of the several valves.
SECTION V.— Cardiac Asthma.
Amongst the diseases of the heart may be justly reckoned one of
the forms of the malady termed in- common language asthma.
This has been too much regarded as independent of disease of the
heart. Long treatises have even been written upon it without ever
mentioning disease of this organ as one of its causes. It is, there-
fore, necessary to notice the subject formally in this place, not only
for the purpose of showing the magnitude of the error, but of
making the reader acquainted with all the habitudes and aspects
of a complaint, which is perhaps the most distressing in the whole
catalogue of human maladies.
It is established by the concurrent testimony of all moderns
conversant with diseases of the heart, that these diseases, no less
than those of the lungs, may constitute the organic causes of
asthma.
A theoretical consideration of the subject leads, in my opinion,
to the same conclusion ; for, on tracing asthma back to its source,
we shall find that, whatever be its proximate cause in different
cases, it is connected, in all, with the same ultimate circumstance ;
namely, inadequate oxygenization of the blood, and the resulting
want of breath, which, through the "incident excito-motory"
branches of the pneumogastric, excites the "reflex" action of the
"true spinal" nerves on the muscles of respiration. For instance,
inadequate oxygenization of the blood results in all ordinary cases
from one or more of three proximate causes: viz.
A. Insufficient admission of air into the bronchial tubes and
air-vesicles.
B. Insufficient exposure of the blood to the air admitted, in con-
sequence of a less pervious state of the mucous membrane than
natural.
0. Insufficient admission of blood into the lungs.
It will be found that, to one or more of these causes, all !he
varieties of dyspnoea and asthma are referable.
CARDIAC ASTHMA — PAROXYSM DESCRIBED. 377
All the varieties of asthma — to give an approximative statement
probably very near the truth — are comprised under the following
heads : —
1. From chronic dry catarrh, and the emphysema resulting from
it.
2. From pituitary catarrh (humoral asthma) whether acute or
chronic, but more especially the latter, and the pulmonary oedema
resulting from it.
3. From mucous catarrh, especially chronic.
4. From organic disease of the heart.
5. From purely spasmodic constriction of the bronchial tubes.
I do not include amongst the varieties, one from the compression
of the lungs by hydrothorax, by tumours, by imperfectdescent of the
diaphragm, &c, because these rarely occasion what can strictly be
called asthma. Before examining the above varieties it may be
premised that, whatever be the organic cause, all suppose the super-
addition of bronchial spasm, as will be explained under the fifth
variety.
1. Chronic dry catarrh is attended with intumescence of the
internal membrane of the bronchial tubes. The intumescence
exists principally in the smaller tubes, which are sometimes com-
pletely obstructed by it; but it is also found in the larger. Andral
has seen the bronchial trunk of a lung so contracted by this intu-
mescence, that the air could scarcely enter ; and in another case, the
third and fourth bronchial divisions were contracted by the same
cause (Clinique Med. seconde partie, obs. ii. et iii.). Further, the
tubes are more or less obstructed by an exceedingly viscous mucus,
often as dense as the vitreous humour of the eye ; and when the
dry catarrh is universal or very extensive, it is almost invariably
productive of emphysema.
2. Pituitary catarrh is attended with moderate intumescence,
slight softening, and partial redness of the pulmonary mucous
membrane — a state intermediate between sanguineous and serous
congestion, but partaking more of the latter. The quantity of
phlegm expectorated, always considerable, is sometimes enormous,
amounting to from four to six pints of thin glairy fluid in twenty-
four hours.
The air-passages being obstructed partly by the intumescence of
their mucous membrane and partly by this fluid, it necessarily fol-
lows that there is an insufficient admission of air into the lungs.
3. Mucous catarrh is accompanied with more or less tumefac-
tion of the bronchial membrane and obstruction of the calibre of
the tubes. The expectoration, though less copious, and different
in quality from that of pituitary catarrh, is, notwithstanding, fre-
quently abundant, amounting to one or two pints or more in the
day. Consequently, there is an insufficient ingress of air into the
lungs.
In all the cases now mentioned, the second cause of inadequate
oxygenization of the blood is, likewise, for the most part, in operation ;
378 HOPE ON DISEASES OF THE HEART.
viz. the mucous membrane being thickened, it is less pervious to
air<; and its mucus, the natural function of which is to expedite
the combination of oxygen with the blood, probably discharges this
function less perfectly, in consequence of an alteration in its chemi-
cal qualities.
4. Disease of the Heart. — Sometimes, from this cause, blood
exists in the lungs in excess ; as is the case when the right ven-
tricle is hypertrophous, or the left side of the heart obstructed ; or,
still more, when these two affections co-exist : also when the cir-
culation is merely accelerated, as by palpitation, running, or by
slighter efforts in corpulent persons. Now, under all these circum-
stances, there is inadequate oxygenization of the blood ; or, in other
words, there is an excess of venous blood in the lungs : first,
because the quantity of blood admitted exceeds its due proportion
to the air in the organ ; secondly, because the engorgement of the
mucous membrane on which the blood ramifies, constricts the
bronchial passages, and prevents the free ingress of air, as proved
by the feebleness of the respiratory murmur. Hence, want of
breath is a necessary consequence of an excess of blood in the
lungs.
Sometimes blood does not enter the lungs in sufficient quantity,
constituting the third cause of inadequate oxygenization ; and this
may arise from the weakness of the right ventricle, from an obstruc-
tion in its mouth, or from increased resistance on the part of the
lungs ; as, for instance, during sleep, when the respirative function
is less active. Hence results the stimulus of want of breath, and
dyspnoea. Cases exemplifying this will shortly be adduced : mean-
while it may be illustrated by a simple physiological experiment,
viz. by making and sustaining a full expiration. This is attended,
not only with a deficiency of air, but also with a deficient influx
of blood into the lungs, as is proved by the lividity of the face which
ensues, by the elevation of the fontanel in infants; by the rise of
blood in a tube inserted into the jugular vein ; and lastly, by expe-
riment ; for I have demonstrated above, (p. 46,) that, on suspending
artificial respiration in a rabbit, the heart instantly became gorged,
of a black colour, and distended to nearly double its natural size —
a phenomenon which renders it sufficiently manifest that, when
the lungs are exhausted of air, the blood does not freely enter them.
Now, the sensation of want of breath experienced on making a full
expiration is familiar to every one, and it becomes intolerable if the
expiration be long sustained.
5. Spasmodic constriction of the bronchial lubes is presumed to
exist, first, because, according to the researches of Reisseissen and
others, the bronchial tubes are provided with muscular fibres, and
all muscles are liable to spasm : secondly, because asthma is occa-
sionally found to occur without any organic cause (so far, at least,
as our senses enable us to judge) sufficient to account for it : thirdly,
because every form of organic disease above described, both of the
lungs and the heart, may exist without causing dyspnoea of such
CARDIAC ASTHMA PAROXYSM DESCRIBED. 379
intensity and of such a character as to constitute asthma properly
so called. Thus, many have intense chronic bronchitis and pro-
fuse expectoration without any asthmatic dyspnosa; and I have
known a patient with a contraction of the mitral orifice to the size
of a small pea, and likewise with dilatation and softening of the
heart and profuse expectoration, pass through a period often years
to her grave without ever experiencing a paroxysm of asthma,
though a (e\v steps across the room were sufficient to excite
dyspnoea. (Mrs. — 1 — n.)
Hence, I apprehend that whatever be the organic cause of
asthma, it requires for its production the superaddition of a state
of the nervous system leading to spasmodic constriction of the
bronchial tubes. Why some should exhibit this state and others
not, is one of the arcana of the nervous system ; but observation
has shown that the state is constitutional and often hereditary.
Admitting that the spasmodic constriction of the bronchial tubes
does take place, it is obvious that it will more or less close these
tubes against the ingress of air; and this closure, again, by pre-
venting the free expansion of the lungs, will impede the influx of
blood. Whence there is a double cause for the inadequate oxyge-
nization of the blood, and, consequently, for the production and
maintenance of the asthmatic paroxysm.
From all that has been said, we are now led to the resulting
inquiry — what is the essential difference between asthma from
disease of the heart and that from disease of the lungs. Putting
aside that variety of asthma which, as not being attended with any
visible organic derangement, (though it is, notwithstanding, highly
probable that one exists,) may be regarded as mainly, if not wholly
spasmodic, there does not appear to be any essential difference
between the remaining varieties. Their organic causes are diver-
sified, but they all ultimately produce the same effect, and it is the
effect which constitutes the essence of the disease. This effect is
inadequate oxygenization of the blood, which causes "excitant"
want of breath ; and this, when the case is really asthmatic, i. e.
more than what, may be called mere dyspnoea, occasions spasmodic
constriction of the bronchial tubes, and its consequence, the
asthmatic paroxysm.
We now proceed to the more particular consideration of asthma
from disease of the heart.
This variety comprises, according to my observation, by far the
greater proportion of the most severe and fatal cases of the disease.
Some are of opinion that in other varieties the patient experiences
an equal degree of suffering during the continuance of the par-
oxysm. I cannot say that this is consistent with my own obser-
vation. Though the same words may suit for the delineation of an
attack of each variety, my feeling and conviction is, that I have
never seen the patient suffer such intense and suffocative agony as
in the variety from organic disease of the heart.
380 HOPE ON DISEASES OF THE HEART.
Until the discovery of auscultation had in some degree dissipated
the deep obscurity of the affections of this organ, the fact that they
were a cause of asthma was scarcely known : and, even at the
present day, there are few errors more common than that of attri-
buting asthma to other causes, when it originates solely in the
heart. For instance, a theory of this description which has for the
last half century been more widely disseminated than perhaps any
other, consists in ascribing asthma to a spasmodic or convulsive
contraction of the external muscles of respiration, much dependent
on habit.
Now, the action of these muscles, so far from being morbid or
dependent on habit, is a natural, instinctive and salutary effort to
prevent suffocation, the stimulus to which consists in an exagge-
ration of that which excites the muscles in ordinary respiration —
namely, as above explained, the want of breath, resulting from in-
adequate oxygenization of the blood. Nothing is more common,
for instance, than to see a patient with diseased heart, while sleep-
ing tranquilly, start up and begin to respire with violence. Here
it is obvious that the necessity for violent respiration preceded the
act ; and the necessity depends on impeded transmission of blood
through the heart and lungs ; for starting is invariably accompa-
nied by palpitation, and preceded by frightful dreams, or some sen-
sation of prsecordial distress, indicating an obstructed circulation.
I have frequently examined the heart and lungs by auscultation
immediately before the supervention of a paroxysm of dyspnoea,
and have always found that the heart began either to palpitate, or
to act in that irregular, confused, and, as it were, struggling man-
ner, which denotes its engorgement. I was therefore enabled to
tell the patient that difficulty of breathing was coming on, to
which, with some astonishment, he would reply in the affirmative,
being himself forewarned of the approaching accession by a feeling
of anxiety and straitness in the praecordia. The fact is so uni-
versally true, that any one may satisfy himself of it by entering an
hospital and gently placing a patient with orthopncea from disease
of the heart, in a rather uneasy position, when the series of pheno-
mena described will become manifest.
Dr. Burrows communicated to me the particulars of a case,
recently under his observation, in which the respiration was alter-
nately violent and tranquil under the following circumstances.
The patient dozed for a few minutes at a time, during which his
complexion became livid, and his pulse more and more feeble, op-
pressed and irregular. He then started up, and, after a few violent
wheezing respirations, relapsed into the same calm doze. In this
case the mitral orifice was contracted to the si2e of a pea. Now,
there can be little doubt that as, during sleep, the stimulus of want
of breath is less felt, and the muscles of respiration are, conse-
quently, less excited by it, — in simple language, as the respiration
is more feeble during sleep, the lungs were not, in the present
case, kept sufficiently expanded to admit of an adequate circulation
CARDIAC ASTHMA — PAROXYSM DESCRIBED. 381
through them : whence ensued engorgement of the heart and
venous system of the body, with insufficient arterialization of
blood in the lungs, and the necessity for breathing resulting from
it, which series of phenomena was relieved by the succeeding
violent respirations. I have frequently observed this series of phe-
nomena in a greater or less degree: occasionally even in coma. In
another case, violent gasping and wheezing respiration, lasting
from. a few seconds to two or three minutes, occurred at intervals
of four or five minutes, during which the patient dozed, even
though sitting erect on a stool and undergoing a stethoscopjc ex-
amination ; and this series of actions continued so long as the
patient remained disposed to sleep in that situation. Jn another
case of great dilatation and softening, the precise symptoms de-
scribed by Dr. Burrows occurred for the last week of the patient's
life, whether he was awake or asleep, except when calmer sleep
was procured by mild opiates. In a third case, a lady had, for
several years, observed her husband's respiration, while he was in
the horizontal position, but not in the raised position, to be as fol-
lows : — after every four or five respirations calmly performed, suc-
ceeded a pause of a few seconds ; then he started with a "convul-
sive motion of all his limbs, and a heaving of the shoulders." She
had watched this continue for hours together, but he was uncon-
scious of it, and generally slept soundly without frightful dreams.
His disease was slight hypertrophy and disease of the aorta.
In all these cases, it is manifest that the action of the muscles of
respiration was consecutive to the obstruction of the circulation,
and that it was not dependent on any spasm of those muscles, but
simply on the necessity for breathing, which instinctively excited
them to a salutary preservative etfort.
Asthma from disease of the heart often imitates the characters of
the other varieties ; and this perhaps for a very simple reason,
that the lungs are in much the same state as in those varieties.
Thus, it is humid or humoral, when there is permanent engorge-
ment of the lungs, causing copious sero-mucous effusion into the
air-passages, as in cases of contraction of the mitral valve. It is
dry, when the engorgement is only temporary, as in cases of pure
hypertrophy. It is continued, when there is a permanent ob-
struction to the circulation ; and any of the varieties may be con-
vulsive, when the heart has sufficient power to palpitate violently.
The worst cases of convulsive asthma from disease of the heart are
those of hypertrophy with dilatation and a valvular or aortic
obstruction.
We shall now examine the state of a patient labouring under
severe asthma from disease of the heart, and then take a more
strictly medical view of the nature and progress of the asthmatic
paroxysm.
The respiration, always short, becomes hurried and laborious on
the slightest exertion or mental emotion. The effort of ascending
a staircase is peculiarly distressing. The patient stops abruptly.
382 HOPE ON DISEASES OF THE HEART.
grasps at the first object that presents itself, and fixing the upper
extremities in order to afford a fulcrum for the muscles of respira-
tion, gasps with an aspect of extreme distress.
Incapable of lying down, he is seen for weeks, and even for
months together, either reclining in the semi-erect posture sup-
ported by pillows, or sitting with the trunk bent forwards and the
elbows or fore-arms resting on the drawn-up knees. The latter
position he assumes when attacked by a paroxysm of dyspnoea —
sometimes, however, extending the arms against the bed on either
side, to afford a firmer fulcrum for the muscles of respiration.
With eyes widely expanded and starting, eye-brows raised, nostrils
dilated, a ghastly and haggard countenance, and the head thrown
back at every inspiration, he casts round a hurried, distracted look
of horror, of anguish, and of supplication : now imploring, in plain-
tive moans, or quick, broken accents, and half-stifled voice, the
assistance already often lavished in vain ; now upbraiding the
impotency of medicine ; and now, in an agony of despair, drooping
his head on his chest, and muttering a fervent invocation for death
to put a period to his sufferings. For a few hours — perhaps only
for a few minutes — he tastes an interval of delicious respite, which
cheers him with the hope that the worst is over, and that his re-
covery is at hand. Soon that hope vanishes. From a slumber
fraught with the horrors of a hideous dream, he starts up with a
wild exclamation that " it is returning." At length, after reiterated
recurrences of the same attacks, the muscles of respiration, subdued
by efforts of which the instinct of self-preservation alone renders
them capable, participate in the general exhaustion, and refuse to
perform their function. The patient gasps, sinks, and expires.
Such are the sufferings, in their worst form, of an asthmatic
from disease of the heart. We have now to take a more strictly
medical view of the nature and progress of the asthmatic paroxysm.
If about to be severe, it is generally preceded by certain premo-
nitory symptoms, which, though not so marked as in ordinary
asthma, are much of the same nature — probably because derange-
ment of the circulation and imperfect oxygenization of the blood
are present in both. In cardiac asthma, however, many of the
nervous symptoms which characterise the ordinary varieties are
often deficient. One of the most common and efficient exciting
causes of cardiac, as of all other asthmas, is derangement of
the stomach, the irritation of which extends to the heart, and
stimulates it to inordinate action. The irritation, according to the
theory of Sir Charles Bell, or the lately revived excito-motory
views of Prochasca, is propagated through the medium of the par
vagum, by which nerves the stomach and heart are closely asso-
ciated. Accordingly, after a feeling of acidity "flatulence, or a load
on the stomach from undigested food, often accompanied with
abdominal distention, the patient experiences pain, weight, and
constriction in the forehead and over the eyes, accompanied (if the
case be one of hypertrophy of the left ventricle) with throbbing of
CARDIAC ASTHMA PAROXYSM DESCRIBED. 383
the temples and the sound of rushing waters. He feels a sensation,
scarcely to be defined, of oppression, tightness and anxiety about
the praecordia, frequently with slight palpitation. Sometimes the
patient is drowsy, listless, restless, irritable, and impatient, not only
of society, but of the attentions of friends: these symptoms, how-
ever, are, in general, more prevalent in ordinary asthma. The
signs described afford the experienced asthmatic well-known assur-
ance of the approaching attack.
They gradually become worse and worse, especially after a
meal, and eventually burst into a paroxysm. The time of the
accession is less regular than in ordinary asthma, being more de-
pendent on the state of the heart, which is liable to accidental
excitement at any moment, from a variety of causes. The fit,
however, as in ordinary asthma, is, on the whole, more apt to
supervene during the evening or early part of the night ; and this,
as appears to me, for two reasons : 1st. the recumbent position is
unfavourable to respiration, the diaphragm ;being pressed upwards
by the abdominal viscera, and the expansion of the chest being
opposed by its own weight. 2d. During sleep, respiration is not
assisted by the will, which, during the wakeful state, from the sen-
sation of want of breath being more acutely felt, is ever ready to
maintain the body in the position most favourable to breathing.
From the co-operation of these two causes, therefore, the circulation
becomes so far embarrassed before the patient is aroused to a sense
of his condition, that it can only be relieved by those violent efforts
which constitute the asthmatic paroxysm. He accordingly awakes,
generally with a start, in a fit of dyspnoea, accompanied either with
violent palpitation, or a distressing sense of anxiety in the pra?cor-
dia and great constriction of the chest, as if it were tightly bound.
He is compelled to assume a more erect posture, and intensely
desires fresh, cool air ; the respiration is wheezing, and performed
with violent efforts of all the muscles of respiration, both ordinary
and auxiliary. The inspirations are high and accompanied with
apparently little descent of the diaphragm, and the expirations are
short and imperfect. The surface is chilly, the extremities are
cold, and the face is pale and sometimes livid.
In cases in which the pulmonary congestion is only temporary,
as in hypertrophy either simple or with dilatation, there is no cough
beyond a few slight and ineffectual efforts, producing little or no
expectoration; and in such cases the fit subsides as soon as the
engorgement of the heart and great vessels is relieved, which nature
generally effects in two or three hours or less, by determining the
blood to the surface and creating diaphoresis. In some instances, I
have known this to be regularly accompanied with a copious secre-
tion of pale urine and a purging alvine evacuation (case of May).
In this case, the attacks recurred, according to the assertion of the
patient, every night for several years.
The pulse, however full, strong: and bounding at first, may,
during the worst of the paroxysm, become feeble and small, and
384 HOPE ON DISEASES OP THE HEART.
the sound and impulse of the heart may be diminished ; and this,
in cases even of hypertrophy; for the organ, being gorged to
excess, is incapable of adequately contracting on its contents.
Such is the nature of an asthmatic fit when the pulmonary con-
gestion is only temporary: the case is different when it is perma-
nent, as in valvular disease and in some extreme cases of dilatation.
For then, there is violent cough in suffocative paroxysms, accom-
panied, at first, with difficult and scanty expectoration of viscid
mucus, but ending gradually in a copious and free discharge of
thin, transparent, frothy fluid, occasionally intermixed with blood.
This evacuation, by disgorging the pulmonary capillaries, affords
great relief to the cough and dyspnoea. As, however, the transu-
dation of the matter to be expectorated into the air-passages, and its
final elimination, are slow processes, paroxysms of this description
are much more protracted than those of dry asthma from hypertro-
phy. They frequently last five or six hours, and I have known
them persist, with occasional remissions, for two, three, or more
days. During the attack, the pulse is quick, small, and weak, often
irregular and intermittent. The slowness which the latter charac-
ters sometimes appear to give it, has led some authors to suppose
that the circulation through the heart is little disturbed in asthma.
This is in some degree true in reference to other varieties of asthma ;
but it is always incorrect in reference to that from disease of the
heart.
As the paroxysm subsides, the anxiety and constriction decrease,
the respiration becomes less frequent, high, and laborious, and
the pulse becomes slower, fuller, and more regular. But some
degree of wheezing and tightness of the chest remain, and the
paroxysm is very apt to return for two or three nights succes-
sively, and sometimes for a much longer period, until the lungs are
freely unloaded by copious expectoration. It may, indeed, con-
tinue to recur at brief intervals for an indefinite period, or the
patient may never be wholly exempt from some degree of asthmatic
dyspnoea.
A severe asthmatic attack from disease of the heart is in general
far more injurious in its consequence than one from an affection of
the lungs.
SECTION VI.— Treatment of Valvular Disease.
According to the foregoing principles, (p. 348,) the exciting causes
of valvular disease are, I. over-tension of the valves by the force of
the circulation ; and 2. inflammation, both acute and chronic.
It has been shown in the chapter on endocarditis, that as it is now
possible to detect this disease with much precision, so it is possible, in
a considerable proportion of cases, to counteract the establishment of
valvular disease by active antiphlogistic and mercurial treatment
during the inflammatory periods (p. 220). It has also been shown
that acute rheumatism is, of all others, the most frequent cause of
endocarditis, and that this frequency may be remarkably diminished
TREATMENT OF VALVULAR DISEASE. 385
by the treatment for acute rheumatism described at p. 186. With
respect to valvular diseases resulting from causes other than inflam-
mation, it is almost impossible to obviate their formation, since there
are no positive signs of the latent mischief but what result from the
disease already formed— from the obstruction itself. As, in the pre-
sent state of our knowledge, we are not acquainted with any means of
removing a. valvular disease once established, whatever be its cause,
the indications of treatment in such cases are, to prevent its increase,
to counteract its tendency to induce hypertrophy and dilatation, and
to relieve the symptoms of an obstructed circulation. The extreme
importance of obviating the supervention of hypertrophy or dilata-
tion, has been explained at p. 354 et seq.
The remedies calculated to answer these indications, are, in gen-
eral terms, such as diminish the force and activity of the circulation :
namely, occasional venesection to a moderate extent, [conjoined with
topical depletion, — P.] in certain cases ; an unstimulating and rather
spare, though sufficiently nutritions diet; a tranquil life, with
respect both to the body and the mind ; and a good state of the
digestive organs and alimentary canal.
The extent to which any remedy must be carried, can only be
determined by the particular circumstances of each case. If, for
instance, the patient be robust and plethoric, depletory measures may
be pursued to a greater extent, and vice versa. In general, if the
valvular obstruction is not very considerable, and there is no hyper-
trophy or dilatation, and no tendency to plethora, an abstemious
light diet, comprising a moderate proportion of animal food, and a
scrupulously tranquil life, with a regular state of the bowels, consti-
tute all the prophylactic treatment that is necessary; and it is satis-
factory to know that, by these means, danger may in many instances
be completely averted. I have several times known patients with a
moderate — even with a rather considerable valvular obstruction,
attain the age of sixty, seventy, and even eighty, though the symp-
toms, judging from their account, had commenced in early life.
On the other hand, if precautionary measures be neglected and
hypertrophy or dilatation superinduced, there is no organic disease
of the heart, except adhesion of the pericardium, which tends more
rapidly to its fatal termination. Hence the great importance of de-
tecting and attending: to disease of the valves in its earliest stage.
When the obstruction is very considerable, has produced hyper-
trophy or dilatation, and is attended with much dyspnoea, orthopncea,
and dropsy, the case is one of the most difficult that the practitioner
can encounter. The most urgent symptoms, however, generally
admit of being removed for a time ; and the amelioration which
takes place is sometimes truly astonishing. But, unhappily, the com-
plaint seldom fails to return with greater or less promptitude. If the
patient be youthful and of a robust constitution, the relapse may
not occur for several months, especially if he have not been affected
with dropsy, or only for the first time ; but if he be of a shattered
constitution, and have previously had severe attacks, the symptoms
11— f 25 hope
386 HOPE ON DISEASES OF THE HEART.
commonly return the moment he resumes any active occupations.
In an ulterior degree of the disease, no sooner are the symptoms
dispersed than they return, though the patient have not been guilty
of any indiscretion. When this is the case, the fatal event is never
far remote, and may be expected to occur at any moment.
The remedies suitable for the treatment of the cases described,
are, abstractions of blood, purgatives and hydragogues, diuretics,
sedatives, revulsives, a well-regulated, moderate, unstimulating diet,
and, what is paramount in importance to all, complete repose.
These remedies, however, are not to be employed at random : so
used, they might not only be unavailing, but directly destructive.
It is only by adapting them to the character of the organic cause of
the disease, and to the constitutional condition, — only, in short, by
a sound diagnosis, that they can be administered safely and effec-
tually. It is necessary, therefore, to enter into further particulars
relative to their nature and mode of application, and this may be
most conveniently done by adverting separately to each.
Blood-letting. — When, with the valvular obstruction, there is
hypertrophy or hypertrophy with dilatation, bleeding [either to-
pical1 or by the lancet — P.J is generally necessary, and may be
repeated, in small quantities of four to six ounces, two, three, or
more times, according to the strength of the patient and the
urgency of the palpitation and dyspnoea. It should not, however,
be employed if the patient be anaemic, or on the verge of that state.
It should also be avoided, if possible, in the aged. Some authors,
as Laennec, have recommended that blood-letting be practised in
valvular disease in the unsparing manner of Albertini and Val-
salva. The results of my own experience lead me to dissent en-
tirely from this doctrine. Excessive bleeding cannot remove the
valvular obstruction — cannot, therefore, cure the disease ; con-
sequently its employment with this object is inappropriate. It is,
moreover, directly injurious ; as it reduces the patient to a state of
anaemic debility, which increases his palpitation, renders his circu-
lation more liable to be embarrassed by the valvular obstruction,
and greatly augments the disposition to general dropsy. I have
always observed blood-letting to be most serviceable in valvular
disease when carried only just so far as to relieve the existing
urgent symptoms without encroaching on the constitutional powers.
If, instead of hypertrophy, dilatation, either simple or attenuated,
be conjoined with valvular disease, blood-letting is less necessary,
and is more injurious if carried to excess. It should be resorted to
reluctantly; only when imperiously demanded by excessive dys-
pnoea, which other means have failed to relieve ; the least quantity
that suffices to afford relief should be drawn; and the depletion
should not be repeated if it can possibly be avoided. Attention to
these rules is still more necessary in the aged. The greater the
ll Cups applied between the shoulders, over the root of the lungs, produce
excellent results. — P.]
TREATMENT OF VALVULAR DISEASE. 387
valvular obstruction, the greater is likely to be the embarrassment
of the circulation, with its train of formidable symptoms, if the
power of the heart and the system be reduced below a certain
point. Of this I feel satisfied from reiterated observations.
Diuretics. — When there is dropsy and a scanty secretion of
high-coloured urine, remedies of this class are of the greatest utility.
In most cases, indeed, the dyspnoea, palpitation, cough, &c, de-
crease in the same proportion as the urine increases and the dropsy
disappears. Nor is it only when dropsy has actually appeared
that diuretics are useful. They are remarkably beneficial in any
stage of the disease ; for, by drawing off the serous portion of the
blood, they diminish the quantity, without deteriorating the quality
of that fluid, and thus relieve palpitation and dyspnoea, and obviate
infiltration, without materially reducing the strength.
Diuretics are very variable in their effect, a weaker sometimes
answering perfectly after a stronger has failed. When, therefore,
one does not speedily produce the effect, another should be tried.
The surest way is to employ several at once. A pill consisting of
three grains of blue pill, one of pulv. scillse, and one or half of one
of pulv. digitalis, given three or four times a day, seldom fails : or
it may be given once or twice a day with a draught of Tr. scillae,
mxx. Sp. aetheris. nit. and Sp. Junip. C. comp. aan. 3ss. ad 3i, in
Dec. Spartii. 5iss. twice or thrice a day. I have sometimes found
all these fail until oij or 3nj of infusion of digitalis was added to
the draught. Its effect, however, must be carefully watched.
Bitartrate of potass is always a valuable auxiliary, and may be
given to the extent of 3 i j or 5iij in twenty-four hours, either in the
form of a drink, of electuary with honey, or suspended in the above
draughts. Some writers strongly recommend doses of 5SS. twice
or thrice a day, and I have seen them produce surprising effects on
dropsy, but some care is requisite to obviate hypercatharsis. The
acetate and hydriodate of potass and Tinct. Lyttce are also valuable
diuretics. In old or feeble subjects, a vehicle of Inf. Gentiange or
Cascaril. is useful as a tonic.
In very feeble and reduced patients, dropsy should not be too
rapidly evacuated ; as the process is attended with a degree of ex-
haustion which is often fatal. The period, indeed, immediately
succeeding the disappearance of dropsy is, on this account, one of
the most critical. The older physicians were aware of this, and
ascribed it to the accumulation of fluid in the internal cavities.
Such, however, is not always the cause ; for, in cases that ter-
minated fatally at the period alluded to, I have frequently as-
certained, both by auscultation, percussion, and post-mortem ex-
amination, that the internal and external dropsy disappeared
simultaneously. The exhaustion alluded to should be obviated by
strong beef-tea, or animal food if it can be digested, and, if ne-
cessary, by stimulants, of which Sp. armorac. C. or gin punch,
being diuretic, are the best.
Purgatives. — When diuretics fail to remove dropsy, purgatives
25*
388 HOPE ON DISEASES OF THE HEART.
will frequently produce that effect. The two classes of remedies
may, indeed, be combined with great advantage, when the patient
is strong enough to bear them. The drastic hydragogue pur-
gatives are the most efficacious, as tinct. jalapae, elaterium, &c.
The effects of the latter are sometimes truly astonishing. I have
seen an extreme, universal anasarca removed by it in three or four
days. The remedy is apt, however, to be excessively violent in
its operation, and it should, therefore, be given to strong subjects
alone, or the weakly and aged should be carefully watched. As
its effect varies in different individuals, it should be tried at first in
small doses, as from one eighth to one fourth of a grain. "With
caution it may be carried to two grains. I generally give it in the
form of pills with pulv. capsici, which obviates its griping effect;
sometimes I add a grain or two of calomel, which prevents vomit-
ing. A single pill should produce six or eight watery evacuations,
and it may be given two or three mornings successively, or every
second or third morning, according to the strength of the patient.
If much exhausted, he may take gin punch more freely. All
the other purgatives may be useful, especially such as produce
watery evacuations. A very good one is, the infusion of senna,
with tinct. jalapae %i, and tartrat. or acetat. potass 3ij. toiv. I have
several times known both diuretics and hydragogues signally fail
till the patient was put upon a dry diet.
An occasional purgative is sometimes very beneficial though
there be no dropsy ; as, for instance, when an asthmatic attack has
appeared to be induced by an excess of bile, by undigested food, or
by acrid or long-detained faeces in the intestines. Under such cir-
cumstances, a purgative often alleviates, and sometimes terminates
the attack. Except with a view of removing dropsy, or plethora
in cases where hypertrophy is conjoined with valvular disease, fre-
quent, systematic purging should be avoided on the same principle
as blood-letting : viz. lest it should too much reduce the system and
occasion anaemia.
Diaphoretics. — When there is anasarca, cutaneous transpiration
contributes very powerfully to remove it. A lady under my care,
and subject to frequent attacks of anasarca, often found the
swelling disappear in twenty-four hours with copious perspiration.
Strong, stimulating sudorifics, however, should be avoided, as they
are both too debilitating and too exciting to the circulation. Gen-
tle saline diaphoretics are the best, and their effect may be
promoted by warm clothing, and the occasional use of the warm
bath to keep the skin soft and open. When there is no anasarca,
and no permanent pulmonary engorgement with expectoration,
diaphoretics, beyond warm clothing, are of little use, except occa-
sionally, to relieve asthmatic attacks. For the latter purpose I have
generally found them of great utility ; but, as internal remedies of
this class are slow in their operation, they should be assisted by
fomenting the hands and feet, or immersing them in warm water,
at the same time keeping the trunk covered. If perspiration can
TREATMENT OF VALVULAR DISEASE. 389
thus be gently elicited without heating and stimulating the patient,
it is one of the most effectual means of curtailing a paroxysm.
Nature herself indicates the remedy, as an asthmatic paroxysm
often terminates with spontaneous diaphoresis. In one patient
under my observation (May) this occurred nightly, and to an
extreme degree, for several years.
Emetics. — These are extremely useful, or extremely pernicious,
according as they are judiciously given, or the reverse ; and
it is only by a sound diagnosis that the practitioner is enabled
to judge whether they can be safely administered or not. When
there is an undigested, bilious or acid load on the stomach, exciting
a fit of palpitation or asthma, its removal by an emetic often
affords instantaneous relief. But the medicine should be one
which simply evacuates the stomach without much shaking
the system, as ipecacuan, with sulphate of copper or of zinc, but
by no means potassio-tartrate of antimony.
If the disease of the heart and the embarrassment of the circu-
lation be great, even such an emetic cannot be given without
danger of aggravating all the symptoms. I have seen emetics, ad-
ministered under these circumstances, exasperate and prolong the
paroxysm, increase the frequency of its recurrence, and speedily
bring the patient to his grave. They may even cause death during
the paroxysm. Their dangerous effect consists in their increasing
the engorgement of the heart and the obstruction of the circulation.
For this reason, they should not be ventured upon in disease of
the heart, simply for (he object of promoting expectoration — an ob-
ject which may by other means be much more safely and effectually
accomplished. In other varieties of asthma, on the contrary, espe-
cially that from pituitary catarrh, they are peculiarly beneficial by
promoting the expectoration of the immense accumulations which
take place in the lungs. Hence the importance of carefully distin-
guishing between these two classes of cases.
I have said thus much respecting emetics, because they have
been alternately both extolled and decried, the parties using them
under different circumstances, and neither perfectly understanding
on what their good or bad effect depended.
Though emetics are objectionable except for the purpose of
evacuating the stomach, small doses of ipecacuan or tartrate of an-
timony are useful as diaphoretics and expectorants. When the
obstruction of the circulation is great, they cannot safely be carried
to nausea, as this state is apt to bring on a languor of the
circulation which leads to the formation of polypi in the heart.
In the case of a lady lately under my care, nausea came on unex-
pectedly, and independent of tartar emetic, at the moment when she
had just been relieved of an excessive dropsy : it was followed by
suffocating dyspnoea, an imperceptible pulse, and other symptoms
indicating the formation of a polypus in the heart. She died in a
week, and the polypus was found.
Puncturing. — When dropsy has failed to be relieved by other
390 HOPE ON DISEASES OF THE HEART.
means, and the cutaneous tension has become intolerable, the
practitioner is compelled to resort to puncturing. I say compelled,
because the remedy is a last and dangerous resource. The
danger, however, may be considerably diminished by making 20
to 30 small punctures with a grooved needle in the thighs and
trunk, but never below the knee, and allowing the fluid to ooze
slowly during four or five days or a week. When incisions are
made with a lancet or scalpel, especially below the knee, and the
fluid is evacuated quickly, as in twelve to forty hours, the patient,
according to my observation, generally dies. This event some-
times results from sloughing of the incisions, but more commonly
from exhaustion induced by the sudden evacuation of the fluid. In
one instance I saw the patient die from hemorrhage.
Setons, issues, and blisters on the precordial region, are of no
use unless there be chronic inflammation of the heart : in other
cases, the pain and irritation that they occasion are often injurious.
Expectorants. — When there is permanent engorgement of the
lungs, free expectoration always affords relief, and I have seen great
dyspnoea result from its suppression by an incipient catarrh, a dry
sharp atmosphere, and even a dose of laudanum. Many asthmatic
fits dependent on valvular obstruction terminate with copious ex-
pectoration of thin sero-mucous fluid. This secretion, therefore,
should always be maintained when there is a tendency to it.
As the stomach in disease of the heart is extremely fastidious and
delicate, oily, sweet, and nauseous expectorants should be carefully
avoided. Squill with an acid, as the acetic or nitric, has been
found by experience to be the most efficacious remedy of this class.
Vinegar of squill has been highly extolled by Floyer, and Tinct.
Scillae, glt x. Acid. Nitrici, gu vi. Extr. Hyoscyami, gr. iij. and
Aquae purae, giss, as a draught every three or four hours during
the paroxysm, is the favourite prescription of Dr. Bree for the
asthmatic paroxysm of his first species, i. e. " from effused serum
in the lungs." Mist, ammoniaci, though in general too heating for
the young, is a useful expectorant for the old, when sufficiently
diluted. The same may be said of the decoction of seneka. Ipe-
cacuan and tartrate of antimony, in small doses, are valuable ex-
pectorants as well as diaphoretics. They may be carried to a
slight degree of nausea, if the obstruction of the circulation is not
very great. Phlegm accumulates during sleep, and it is for this
reason principally, that the patient suffers more on first rising in
the morning. The elimination of the phlegm is greatly facilitated
by a cup of any hot fluid, especially coffee ; and, to allay the ner-
vous irritability of the lungs which generally leads to coughing
before the phlegm is sufficiently detached to be thrown off with
ease, I have found from half a drachm to a drachm of tinct. cam-
phorae comp. of great utility.
Expectorants should not be constantly given, but only to relieve
an asthmatic paroxysm, or to restore the pulmonary secretion when
accidentally suppressed.
Gases. — The effects of atmosphere on asthmatics are so diversi-
TREATMENT OF VALVULAR DISEASE. 391
fied that they can scarcely be reduced to any general rule. When,
however, expectoration is habitually copious, a moist warm atmos-
phere favours it, probably by relaxing the pulmonary vessels. A
clear, sharp air, on the contrary, checks it, and thus increases dys-
pnoea. Again, such an air relieves dyspnoea when it depends, not
on engorgement of the lungs, but on a languid action of the heart,
as in dilatation with attenuation ; and this it does by stimulating
and bracing the system, and causing a freer circulation through the
lungs and more perfect arterialization of the blood. Electricity ap-
pears to act in the same way when it produces any good effect. I
have never tried the inhalation of oxygen, but it is highly com-
mended by Dr. Beddoes and others : and it is rational to think that,
in suffocative dyspnoea from retardation of the blood in the lungs, it
would relieve the anxiety and straitness by causing a more perfect
arterialization.
Smoking tobacco or stramonium sometimes affords extraordinary
relief to asthmatics, and this it does partly, perhaps, by increasing
the bronchial and salivary secretion, but more especially by its se-
dative and antispasmodic effect in tranquilizing the nervous system,
resolving the bronchial spasm, and allaying the sensation of want
of breath. The experience of the patient is the only certain crite-
rion of its utility. In many cases I have certainly seen it pre-
judicial. Its utility is the greatest in those who are of a highly ner-
vous, irritable habit, and in whom asthma displays most of the
spasmodic character.
Antispasmodics. — While the Cullenian doctrine, that spasmodic
constriction of the bronchi was the sole cause of asthma, prevailed,
remedies of this class were much in vogue ; hut experience has not
realised the high expectations to which the theory gave rise, — a
result which is not surprising, since it has been shown that there is
almost always an organic cause in addition to the bronchial spasm.
Antispasmodics are useful auxiliaries, but cannot be depended upon
alone. When they contribute to diffuse and equalise the circulation
in disease of the heart, they are beneficial : when they fail to pro-
duce this effect, they are of little use. In an incipient paroxysm
from slight disease of the heart, I have frequently found a draught
of sp. ammoniae aromat. or foetid, with aether and laudanum,
promptly restore the colour to the face, and warmth with per-
spiration to the skin, with general relief. In one case of hy-
pertrophy with dilatation, adhesion of the pericardium, and aortic
regurgitation, a glass of gin and water had always the effect.
Sometimes gr. x to xv of carbonate of ammonia is more efficacious
than any other remedy. The solution of assafcetida has also
appeared to me to be very powerful, but few patients can be
prevailed upon to take it.
In most instances, the antispasmodic, whatever it be, is produc-
tive of eructation, and to this, in some measure, I attribute its benefi-
cial effect, as flatulence alone suffices to occasion a paroxysm. The
eructation sometimes occasioned by the remedies themselves, espe-
cially aether, must not be mistaken for the extrication of real flatus.
392 HOPE ON DISEASES OF THE HEART.
When the paroxysm is fully established, and results from a great
degree of organic disease of the heart, antispasmodics have little or
no effect in affording relief; and large doses of sedatives, as opium,
hyoscyamus or conium, or of stimulants, as aether, often prolong it.
In conjunction with other means, however, moderate doses may be
tried, and, if the patient feel himself relieved, they may be con-
tinued, and vice versd.
Digitalis, according to my experience, is an excellent adjunct to
an antispasmodic draught: g" xx or xxx of the tincture may
be given every three or four hours, with gu vi to x of tinct. opii,
or, if that disagree, of hyoscyamus, in cinnamon water. Care
should be taken to intermit the digitalis before its specific poisonous
effect is produced.
In suffocative, agonizing orthopnoea, when the restlessness and
jactitation of the patient aggravates the distress, I have often found
narcotics afford great relief simply by, inducing sleep and a
diminished sensation of suffering, and they should always, I think,
be used under these circumstances, to procure the patient a re-
mission when the fatal event is close impending. The doses should
be small ; as, in this oppressed state of the brain, average doses are
very apt to occasion narcotism.
Stomachics. — The correction of dyspepsia is of the first import-
ance in organic disease of the heart; as palpitation is often depen-
dent upon it alone. Two gentlemen at present under my care for
hypertrophy with dilatation, never suffer palpitation, dyspnoea, or
headache, except when affected with acidity, flatulence, &c. Such
cases are often mistaken for " the stomach" alone ; — a most dange-
rous mistake. Of the individuals alluded to, one has had a fit of
apoplexy, and the other has been repeatedly rescued from it by
prompt cupping. When there is acidity, antacids, of which chalk
is the most certain, should be freely given every third or fourth
hour, its constipating effect being counteracted by the previous or
simultaneous exhibition of a kw grains of rhubarb. I have already
stated that the stomach, if loaded, should, in the first instance, be
evacuated by a gentle emetic, copious draughts of tepid water or
chamomile tea being taken to ensure its full and easy effect. This
treatment will generally terminate an attack dependent on dys-
pepsia, in two or three days, and sometimes in as many hours.
Towards the close of the attack, sedatives, as opium or hyoscyamus,
assist by tranquilizing the nervous system.
Not only antacids, but also acids themselves, have been proved by
experience to correct acrimony of the stomach accompanied with
flatulence and distention. Their efficacy is the greatest when the
acrimony is bilious, and they then act, in all probability, both by neu-
tralizing: the alkaline qualities of the bile, and exciting the stomach to
an altered and more healthy secretion. That they possess the latter
property, is to be inferred from their correcting acidity and prevent-
ing fermentation even when there is no bile. A sour apple is a
popular remedy for heart-burn. The acids to be employed, are,
TREATMENT OF VALVULAR DISEASE. 393
the mineral acids much diluted, and also the acetous. Saccharine
acids, as oxymel, acescent fruits, raspberry vinegar, &c. should be
avoided, as they are apt to be more injurious by their fer mentation
than beneficial by their acid qualities. Acids need not be tried till
antacids have failed, which is seldom the case.
To give tone to the stomach, bitters are very useful. Infusions
should be employed during the paroxysm, as tinctures are too sti-
mulating; but after the second or third day, when the patient begins
to amend, either the one or the other may be used. The bitters
may be conjoined with the antacids, ccc.
Tonics. — When disease of the heart is of the hypertrophic kind
with increased activity of the circulation, tonics are obviously in-
appropriate: when it is of the dilated kind, with languor of the
circulation and atony of the system, they are remedies of the greatest
value, and it is mainly by them that a complete cure can be effected.
All the tonics may be used according to the discretion of the prac-
titioner. In pale, anaemic subjects, the preparations of iron, in full
doses, for one or two months, are by far the best ; and there is
none preferable to the mist. Ferri Comp. Of the advantages of
bracing air and exercise and of the shower bath, I have spoken in
the article on dilatation. A discreet use of the cold bath also, is
highly beneficial.
Diet. — When valvular disease is complicated with hypertrophy
and increased activity of the circulation, animal food should be
only sparingly allowed, as on alternate days ; but a full proportion
should be restored whenever pallor, weakness and increased pal-
pitation indicate the supervention of anaemia. When dilatation or
softening attends valvular disease and causes feebleness of the cir-
culation, the diet should comprise a full, or even a large, proportion
of animal food, provided the digestion will bear it. In all circum-
stances of valvular disease, the diet should he plain and regular,
dyspeptic articles should be excluded, and the individual meals
should be moderate in quantity.
Such are the remedies to be used in the treatment of organic
disease of the heart. It cannot be too strongly inculcated on the
practitioner, that the disease, when remediable, is not to be cured
by relieving the paroxysm, but by preventing its occurrence.
Every attack gives the patient much ground to retrace : a single
attack may undo the progress of a year, and death may result from
the indiscretion of a day. Great firmness is necessary on the part
of the physician to impress this strongly on the mind of the patient ;
for the latter, when his feeling's are easy, can seldom — very seldom,
be made to comprehend that the necessity for his rigid adherence
to medical, regiminal, and dietetic discipline, is equally imperative.
The practitioner, however, is not the less to study the means of
relieving the paroxysm ; not only because, in it, he has perhaps the
greatest of human sufferings to alleviate, but because, by curtailing
the attack, he increases the chances of a cure.
394 HOPE ON DISEASES OF THE HEART.
CHAPTER X.
ANEURISM OF THE AORTA.
SECTION I. — Classification, Nomenclature, Anatomical Characters and Formation of
Aneurisms of the Aorta.
Aneurism ('A^^y^a, to?, to, arteriae dilatatio et inde ortus tumor,
from 'avev^vvu, dilato, amplio) is an enlargement of a portion, or the
whole, of the circumference of an artery.
Aneurisms of the aorta are divided by authors into four species.
1. Dilatation, which is an enlargement of the whole circum-
ference of the artery.
2. True aneurism, which is a sacculated dilatation of a portion
only of the circumference, or of one side of the artery.
3. False aneurism, which is formed by ulceration or rupture of
the internal and middle coats, and expansion of the external or cel-
lular into a sac. It is called primitive when all the coats are
divided, as by a wound ; and consecutive when it is consequent on
ulceration or rupture of the internal and middle coats.
4. Mixed aneurism, which is a supervention of false upon true
aneurism, or upon dilatation: that is. after dilatation either partial
or general of all the three coats, the internal and middle burst, and
the external alone expands into a further sac, surmounting the origi-
nal dilatation or true aneurism.
[5. Dissecting Aneurism.. — This form of aneurism should be added to the
preceding, as a fifth variety. It arises from the rupture of the internal coat
and the partial laceration of the middle coat of the artery, in consequence
of which, blood passes between the laminoe of the middle tunic, separating its
internal from its external layer. The infiltration of blood in this manner,
driven onward by the force of the circulation, often causes a separation of the
laminae to a considerable extent: sometimes a factitious route may be
formed for a portion of the blood, which is returned into the canal of the
aorta by a rent corresponding in character with the first laceration, and thus
cause two channels for the passage of the blood. (Vide plate of dissecting
aneurism. — P.]
1. Dilatation, or Enlargement of the whole circumference of
the Aorta. — When the coats of the aorta, whether from inflamma-
tion or from any other morbid action, have become diseased, they
lose their elasticity, a quality which resides principally in the
middle tunic. As fluids press equally in every direction, the blood
propelled by each contraction of the heart into the aorta exerts not
only a longitudinal, but a lateral force, which expands the vessel,
and constantly tends to enlarge its calibre. The elasticity of the
arterial walls, in the^ healthy state, enables the vessel to resist this
expansive force, and to regain its previous calibre after the diastole.
Consequently, when the elasticity is impaired or lost by disease,
the vessel, not being able to regain its original dimensions after
each diastole, becomes permanently dilated, and this take place to
■
ANEURISM OF THE AORTA. 395
a greater or less extent, and with greater or less promptitude, in
direct proportion to the predominance of the distending over the
resisting force.
It very rarely happens that a dilated aorta does not present, in
its interior, some of the morbid changes already described : (see
Arteritis, p. 222:) namely, cartilaginous, steatomatous, athero-
matous, or calcareous depositions, with a thickened, wrinkled, and
fragile state of the internal coat. When such depositions are not
apparent, the walls, according to my observation, are always more
or less indurated, opake and inelastic ; and also sometimes extenu-
ated, particularly the middle coat, and sometimes thickened, with a
softened and easily separable state of the internal coat : — conditions
which are a much more natural cause of dilatation than paralysis
of the middle coat, supposed by some authors to be its cause when
no depositions are manifest.
The ascending portion and arch of the aorta, particularly the
latter, are by far the most frequent seats of dilatation — probably
because they are, from vicinity, most exposed to the expansive
force of the left ventricle ; but the descending portion, both in the
chest and abdomen, is sometimes affected, and the dilatation is then
either uniform throughout the whole length of the vessel, or it con-
sists of one, or even a series, of ovoid or fusiform expansions. The
side of the artery adherent to the spine, and the lesser curvature of
the arch, yield less readily than the other parts. Dilatation of the
aorta does not in general exceed twice the natural calibre of the
vessel, but I have occasionally seen it attain three, and even four
times that size. When such is the case, it frequently presents
many minor bulgings or pouches, which give it a considerable resem-
blance to the transverse arch of the colon. The walls of these pouches
are often extenuated and semi-transparent from horn-like and cal-
careous depositions, and it is here more especially that mixed aneu-
rism is apt to take place ; for the brittleness of the depositions causes
rupture of the internal and middle coats, and the engraftment of
false aneurism upon the true.
Dilatation of the pulmonary artery is extremely rare. I have
met with one remarkable case in which it was enlarged to four
inches and a half in circumference (Wetherall), and another in
which it was rigidly ossified, even beyond its primary subdivisions
in the lungs (Lady R.).
Dilatations, even though pouched, scarcely ever contain lami-
nated coagula ; for the surface is in general too smooth to arrest
the blood: when they do take place, it is in consequence of an
ulcerated or fissured state of the internal membrane which forms
nuclei for the adhesion of fibrine.1 The coagula thus formed occa-
sionally fill up the whole of the dilated portion, and leave the canal
of the artery of its natural calibre.
The great arterial trunks rising at right angles from the aorta,
1 Case by Burns, on Disease of ihe Heart, p. 20G; and by Bertin and
Bouillaud, Obs. xxxvi.
396 HOPE ON DISEASES OF THE HEART.
as the innominata, left carotid, and coeliac, generally participate in
the dilatation : the left subclavian almost always remains exempt ;
without doubt, says Laennec, on account of the acute angle at
which it branches off.
Dilatation takes place not only in the aorta and its immediate
trunks, but sometimes in smaller and more remote arteries, as, for
example, the carotid by the side of the sella turcica, and the arteries
of the circle of Willis, of which I have seen several instances ; the
temporal,1 coeliac, mesenteric, and emulgent,2 with their ramifica-
tions, the arteries of the extremities, and those feeding tumours
of any description, particularly fungus haematodes and the
hemorrhagic ncevus or aneurism by anastomosis of John Bell.
2. True Aneurism, or lateral, partial Dilatation of the Aorta.
— True aneurism differs from dilatation in the circumstances, that it
is an enlargement of a limited portion only of the circumference of
the aorta ; that it generally rises with an abrupt margin : and that
its neck is, in most cases, narrower than the body of the sac (Case
of Hill). Its formation is to be attributed to a loss of elasticity and
resistance in the particular part only that dilates ; and the proofs of
its existence, in contradistinction to false aneurism, consists in the
possibility of tracing the internal and middle coats of the artery
throughout the whole extent of the expansion, and in the presence,
within the sac, of those morbid appearances, which are peculiar to
the internal coats of arteries : such as calcareous, cartilaginous and
atheromatous depositions, slight fissures and small red spots.
These proofs have of late years been so frequently verified by dis-
section, that the reality of aneurism by dilatation of all the coats of
an artery is no longer problematical.
Almost all the aneurisms of the ascending portion and arch are
originally of the true species, but the false is sometimes engrafted
upon them. The tumour generally springs from the anterior, or the
lateral parts of the vessel, while the posterior part and the lesser
curvature of the arch are little, if at all implicated :3 it sometimes
attains the magnitude of a mature foetal head,4 and almost invari-
1 Cruveillier Essai sur l'Anat. Patholog., Paris, 1816, torn. ii. p. 60.
* Journal de Med. par MM. Corvisart, Leroux et Boyer, torn. vii. p. 255.
3 An aneurism, however, of ihe abdominal aorta, a little above the origin
of the coeliac artery, sprung from the posterior side of the vessel, in a case
by Dr. Beatty, Dub. Hosp. Rep. vol. v. p. 183.
4 Corvisart, Journ. de Med. par MM. Corvisart, Leroux et Boyer, torn. vii.
p. 355. Laennec de l'Auscult. torn. ii. p. 691.
[An aneurism of great extent, springing from the posterior side of the
aorta immediately opposite the crura of the diaphragm, was presented to
the editor some time since. It was the case of a man 50 years of age, a
shoemaker, who, " after experiencing great pain in jLhe small of the back,"
which he regarded as lumbago aggravated by his constrained posture, was
obliged, one year after the commencement of this symptom, to discontinue his
occupation in consequence of inability to use his lower limbs. At that time,
upon examination of the physical signs, it was found, that the condition of the
lungs, with the exception of some emphysema at the summit, was normal.
The heart also was in its natural condition, there being nothing abnormal
ANEURISM OF THE AORTA. 397
ably inclines to the right side of the chest, except when it origin-
ates beyond the middle of the arch. When it springs from the
root of the aorta, and the middle and internal coats happen to burst,
there results, not a false aneurism surmounting the true, as in other
parts, but a fatal extravasation into the pericardium. The reason
of this is, that the part of the aorta referred to, is destitute of the cel-
lular tunic, and the pericardium which supplies its place, not being
equally extensible, bursts, rather than dilates into a false aneurism.
In the same way, the deficiency of the cellular coat in the arteries
of the brain, causes their rupture to be followed by an apoplectic
extravasation, instead of by the formation of a false aneurismal sac :
of true aneurisms, however, I have met with two instances.
It has been stated by a recent writer that a preparation in Mr.
Hunter's collection subverts the doctrine that " false aneurism does
not form at the root of the aorta." The preparation of which he
speaks, however, scarcely subverts this doctrine, since it is not one of
false aneurism ; for the middle coat is perfect, the internal one alone
being either diseased, or removed, (which is doubtful,) at the base
of the sac. Though it has been denied by authors that false aneu-
rism may form at the root of the aorta, it has not been denied that
true may. I have myself seen it in more than one instance (e. g.
case of Mitchell). Coagula are occasionally, but not often, found in
true aneurisms ; they are usually in masses, adherent by peduncles,
and seldom in layers investing the walls, unless the aneurism be
very large : the reason of which is, that, the mouth of the sac being
in general spacious, the blood has a sufficiently free ingress and
egress to circulate with force, while the surface of the sac is so smooth
as not to arrest the fibrine and cause its deposition in layers. But
when the circulation is by any cause enfeebled, the blood stagnates
and forms coagula in masses, which become adherent by limited por-
tions or peduncles. True aneurism is much more rare than either
false, mixed, or dilatation.
either in its impulse, rhythm of its action, or the extent of its pulsations.
The pulsations of the arteries in different situations were natural. The body
was much emaciated, and the aorta could be traced throughout the abdomen,
and at least one half of its anterior circumference could be distinctly felt to be of
its usual size, and no abnormal impulse or sound existed. When the stomach
and intestines were not distended, a small tumor, unattended by pulsation, could
be detected beneath the left hypochondrium. The pain, which was always
referred to the middle portion of the back, was described by the patient as
being of" a burning or eating character, rather than sharp."
Death took place very suddenly, and upon a post-mortem examination, the
left chest was found filled with blood, proceeding from the rupture of an
aneurismal tumor, which extended from the second lumbar vertebrae to the
sixth dorsal; the osseous portion of the three last dorsal and the first lumbar
were removed by ulcerative absorption. The internal portion of the sac was
lined, as usual, by successive concentrive layers of coagula, and its contents
were in contact with and caused pressure upon the spinal column at the points
where the vertebra had been removed. Two thirds of the anterior circum-
ference of the aorta was. of the natural size, and the sac was formed through
a smallfissure penetrating the internal and middle coats of the posterior portion
of the vessel. — P.]
398 HOPE ON DISEASES OP THE HEART.
3. False Aneurism, or Aneurism by Ulceration of the Internal
and Middle Coats. — Nichols proved, by experiments made before
the Royal Society of London, that when the internal and middle coats
of an artery are divided, and water or air forced into the vessels, the
external coat is distended so as to form a small sac(Philos. Trans,
vol. xxxv. p. 443). In the same manner, when the internal and mid-
dle coats are perforated by ulceration or a fissure, the blood, by its
lateral pressure, gradually raises the external coat and expands it
into a sac, which communicates by a narrow aperture or neck with
the interior of the artery, whose calibre is not enlarged. As the dis-
tention proceeds, the external coat itself gives way, and the sheath
of the vessel next opposes the effusion of blood : finally, when this
also yields, the contiguous parts, whatever be their texture, contribute
to the formation of the sac, they having previously undergone thick-
ening and agglutination by chronic adhesive inflammation, to which
distention or pressure had given rise.
Such is the manner in which the sac is formed in aneurism from
ulceration of the arterial coats. It presents no vestige of the middle
or fibrous coat, nor the depositions connected with the cellular tissue
of the internal membrane; but its inner surface is extremely rug-
ged and unequal from lymph irregularly deposited by inflammation.
To this rugged surface adhere the layers of fibrine subsequently
separated from the blood.
Perforation of the internal and middle coats is not always fol-
lowed by aneurism of the kind described. Laennec met with a
case in which the internal and middle coat had been divided by a
narrow transverse fissure extending over two thirds of the circum-
ference of the artery, and the blood, instead of distending the exter-
nal coat into a sac, had insinuated itself between it and the fibrous,
and dissected them from each other round upwards of half the cir-
cumference of the artery, from the arch of the aorta down to the
common iliacs.1 Fissures of the kind described, result from cracks
or lacerations following the circular direction of the fibres of the
middle coat, or from lesions occasioned by calcareous depositions ;
but the case of Laennec, and two similar ones mentioned by Mr.
Guthrie,2 are the only instances within my knowledge in which a
fissure has been followed by more than a circumscribed effusion of
blood around it, occasioning a slight swelling of the external coat.3
Nichols found this in the body of George the Second,4 and Hodgson
once met with it.5
The late Mr. Shekelton has described, in the Dublin Hospital
Reports, third volume, another, and previously unnoticed kind of
aneurism: the blood had forced its way through the internal and
middle coats, dissected the middle from the external or cellular for
the space of four inches, and then burst again through the internal
1 De l'Auscult. torn. ii. p. 700. 2 Guthrie on Dis. of Arteries, p. 40, 43.
[3 Vide Art. on Dissecting Aneurism. — P.]
* Philos. Trans, vol. ii. p. 269. 6 On Diseases of Arteries, p. 63.
ANEURISM OF THE AORTA. 399
and middle coats into the canal of the artery, thus forming a new
channel, which eventually superseded the old one, the latter having
become obliterated by the pressure of the tumor.
The causes of perforation of the internal and middle coats and
the formation of false aneurism, are, 1st. ulceration, generally oc-
casioned by the detachment of calcareous incrustations, by athero-
matous depositions under the internal membrane, and, more rarely,
by tubercles, or small abscesses in the substance of the fibrous tunic:
2d. rupture or cracking, which takes place when the tunics have
been deprived of their elasticity by cartilaginous, steatomatous,
fungous and calcareous degeneration.1 The immediate or exciting
cause of the rupture is generally some violent exertion or accident ;
and in most instances patients with aneurism date it from some
occurrence of this kind. Rupture does not appear ever to take
place in a perfectly sound artery ; and, if it did, the experiments of
Dr. Jones seem to prove that it would not be followed by an aneu-
rism, as an effusion of lymph takes place, which strengthens the
vessel in the lacerated part.2
While aneurisms of the ascending aorta and arch are, in the first
instance, almost invariably true, though they occasionally become
mixed ; those of the descending aorta are generally false ;3 andthe
calibre of the artery is, with few exceptions, not in the slightest
degree dilated opposite to the tumor.
Aneurism by perforation of the internal and middle tunics, is the
only species of which Scarpa admits the reality: but the inaccu-
racy of his opinions has been fully proved, and, as before stated,
there is no longer any question respecting the actual existence oi
aneurism by dilatation of all the coats.
The cases of false aneurism that are on record, are very nume-
rous. Reference may be made to the works of Lancisi, Morgagni,
Guattoni, Scarpa, Desault, Warner, Hodgson, Home, Laennec,
Bertin, and Bouillaud.
*4. Mixed Aneurism or False Aneurism surmounting' True. —
This species is formed in the following manner. All the three
tunics of the artery first undergo an expansion, which, according
to its form, constitutes either a dilatation, or a true aneurism : as
the expansion proceeds, the internal and middle tunics burst, and
the external, being more extensible, dilates into a sac, surmounting
the original enlargement.
Aneurisms of this description are very numerous.
The true and the mixed varieties of aneurism communicate with
the cavity of the aorta by an aperture more contracted than the
body of the tumor, and presenting a prominent border. This dis-
position of parts has been perfectly described by Scarpa, and admi-
rably represented in his plates.
General Observations on Aneurism of the Aorta. — Haller, and
1 Scarpa on Aneurism, § 20, 21, 22. Laennec de l'Auscult. torn. ii. p. 704.
Hodgson, p. 62.
2 Jones on Hemorrhage, p. 125. 3 1 lately met with a mixed one.
400 HOPE ON DISEASES OF THE HEART.
MM. Dubois and Dnpuytren have remarked a variety of aneurism,
in which the internal membrane makes a hernia through the rup-
tured fibrous coat and lines the sac, which is formed by the exter-
nal or cellular coat. Hernia of the internal membrane may occur,
according to Laennec, in very small aneurisms : he had seen it in
two, which were not larger tr^an cherries; but, when the tumor
increases, the internal membrane speedily bursts. This he found
to have been the case in two other aneurisms which did not exceed
the size of walnuts (De l'Auscult. ii. p. 693). The experiments of
Mr. Hunter, Scarpa, and Sir E. Home prove, that when the exter-
nal and middle coats of an artery are removed, the internal one
does not dilate into an aneurism, but either bursts, or is strength-
ened by granulations arising from its surface, and by adhesions
formed with the surrounding parts.
Corvisart having found several firm, solid tumors of the size of
nuts, intimately adherent to the aorta, whiie the external and mid-
dle coats appeared to be deficient at the point of attachment, was
led to imagine that extraneous tumors, for such he conceived them
to be, becoming adherent to arteries, led to the formation of aneu-
rism.1 Hodgson, on the contrary, regards the tumors in question
as instances of aneurism cured, the sac having been filled up by
lamellated coagula,2 and the volume of the tumor diminished by
absorption ; and Laennec, Bertin, and the best authorities subscribe
to his opinion.
As an aneurismal sac enlarges, the surrounding parts become
involved in its composition. Thus, the bones, muscles and various
other structures, often contribute to its formation. The viscera,
also, become implicated when the tumor is situated in their vicinity;
and the membranes with which they are invested, being distended
to their utmost, finally yield, and the sac bursts into their cavities.
Accordingly, aneurisms frequently prove fatal by discharging their
contents into the lungs, oesophagus, stomach, intestines, bladder, &c.
The size which the tumor attains depends upon the nature of tl^e
surrounding parts, and is very much determined by their extensi-
bility— a property which is almost in direct proportion to the quan-
tity of cellular tissue of which they are composed. Hence it is,
that, when the disease is situated at the root of the aorta, where the
pericardium supplies the place of the more extensible cellular coat
of the vessel, the sac bursts into the pericardium before it has
attained any great magnitude. Hence, also, it is, that in the cra-
nium, where the arteries are destitute of the cellular coat, and are
ill supported by the pia mater and the soft pulpy substance of the
brain, aneurism is extremely rare ; for such a lesion of the coats of
the arteries as would elsewhere give rise to aneurism, is here
attended with rupture and apoplectic effusion. * It has been already
stated, however, that the arteries of the brain are not unsusceptible
of dilatation and true aneurism.
1 Essai sur les Mai. du Coeur, p. 313. a On Dis. of Arteries, p. 127.
ANEURISM OF THE AORTA. 401
One of the first circumstances that almost invariably follows the
formation of false aneurism, is, the deposition of the fibrine of the
blood upon the internal surface of the sac. This deposition takes
place in successive concentric layers, which have a different aspect
according to the date of their formation. The most central consist
simply of blood more or less firmly coagulated, and they are pro-
bably formed subsequent to death : a little farther, the coaguluni is
dryer, paler, arid evidently composed of a larger proportion of
fibrine, with less serum and colouring matter : still farther, are lay-
ers of pure, whitish, yellowish, or greyish fibrine; and finally, in
contact with the walls of the cyst, are layers of the same matter,
but completely opake, of a somewhat friable consistence like dryish
paste, and very closely resembling flesh which has been deprived of
its colour by boiling. The most recent layers adhere to each other
so slightly as almost to float within the sac ; those beneath are
united by a downy or villous cellular tissue, the adhesion being
stronger in proportion as the layers are older. Patches of vivid
red formed by reticulated blood-vessels, are occasionally found in
the fibrine, and blood often penetrates between its layers, and stains
those which are friable, or decomposed. Coagula are softer in some
cases than in others, though the physical circumstances be the same
in both. The difference is probably owing to a difference in the
chemical constitution of the blood, some specimens containing a
larger proportion, and more healthy quality, of fibrine.
From these anatomical characters, it is evident that lamellated
coagula form by successive depositions of the fibrine of the blood ;
and the depositions are accounted for by the stagnation of the blood
within the sac; for it is proved by experiment and observation that
coagulation of this liquid takes place wheneverits course is interrupt-
ed ; hence the polypi that are found in the heart, the great veins and
the arteries, when the circulation through these parts is obstructed.
The coagulation of blood within a false aneurism is favoured by
two circumstances — the narrowness of the aperture of communica-
tion with the artery, and the ruggedness of the interior of the sac.
In true aneurism, as before stated, the width of the aperture of com-
munication and the smoothness of the interior of the sac, are unfa-
vourable to the coagulation, and accordingly fibrinous layers are
very seldom found in those aneurisms unless they be of great size,
although they often contain coagula in masses attached at one part
only, by a peduncle of greater or less thickness.
The thickness of fibrinous depositions within aneurisms is some-
times very great. Most commonly, it is from half an inch to an inch
and a half, but I have seen it exceed three inches. The thickness is
generally greater in one part of the sac than in another. Laennec
has seen fibrinous coagula as compact and diaphanous, as horn
softened to the utmost by heat, and of a thickness exceeding five
fingers' breadth.
Aneurisms, and the diseases of the coats of arteries which precede
their formation, are much more frequent in men than in women.
11 — g 26 hope
402 HOPE ON DISEASES OF THE HEART.
Of sixty-three cases seen by Hodgson, fifty-six occurred in the former
and only seven in the latter (On Diseases of Arteries, p. 87). I have
found the proportion in females rather larger than this, with respect
to aneurism of the aorta; but, with respect to external aneurism, it
is much smaller, perhaps not exceeding one in fifteen to twenty.
The causes of disease of the arterial coats leading to aneurism, have
been fully discussed in the chapter on Arteritis (p. 225.)
[5. Dissecting Aneurism. — This appellation was first given by Laennec to
a form of aneurism arising from a laceration of the internal and middle
coats of the aorta, the blood passing through which, and driven by the expan-
sive force of the left ventricle, instead of forming a pouch, had separated or
dissected the external tunic from the two internal in a considerable extent
parallel to the length of the artery. In the case reported by him, the lace-
ration which occurred near the heart involved more than half the circum-
ference, and the separation of the coats extended from the heart down to the
iliac arteries.1
Two similar cases are given by Mr. Guthrie in his work on the Diseases
of Arteries, and Mr. Shekelton has described, in the third volume of the
Dublin Hospital Reports, another very remarkable form of a similar lesion,
where the blood, after passing through a fissure penetrating the two internal
coats, again re-entered the canal of the artery by a rent through the same
tissues. The above cases are the most remarkable of this form of aneurism
which have been reported until very recently. In the case of George II.,
reported by Nichols, and in that described by Hodgson,2 a circumscribed effu-
sion of blood only took place through the fissure. Morgagni has described
two cases: one in Epistle xxvi, article 15, — in which a separation of the
coats of the artery had taken place to four fingers' breadth, and a rupture into
the pericardial sac: the other case is mentioned in the same epistle, article
21st; this is a case of death from rupture into the pericardial sac after the
blood had passed a short distance along winding sinuses through the coats
of the aorta.
The following cases occurred in the practice of the Editor and of his
friend Dr. Goddard, of the University of Pennsylvania, in the year 1835-36,
which, as they have led to a view of the anatomical lesion different from
that which has been heretofore entertained, are here presented.
Case 1. Case of Dissecting Aneurism of the Aorta resulting from effu-
sion of blood between the lamince composing the middle coat of that vessel.
— The patient was a black woman, aged 75, who entered the Philadelphia Hos-
pital, Blockley, Dec. 20, 1835. Her health had been uniformly good until
eight years previously, when she first experienced slight difficulty of breath-
ing, with some beating of the heart, which was augmented by ascending
heights. During the summer of 1827, whilst using great muscular exertion,
(pumping water,) she was seized with sudden and severe pain at the ster-
num, attended with violent action of the heart, and a sense of suffocation.
The pain increased in violence, and after remaining fixed in front of the
chest for two weeks became lancinating, extending from the sternum to the
back, and was attended by a short cough, but, (the patient slated,) without
marked fever. The pain continued nearly three months; upon its cessation
the increased dyspnoea prevented laborious exertion. The cough and diffi-
culty of breathing remained, varying in intensity at different seasons, being
less distressing during the summer, whilst they were-aggravated in the win-
ter. The dyspnoea and palpitations were greatly increased after an attack
of cholera, in 1833. During the four years preceding her entrance in the
hospital she experienced severe uterine pains with bearing down sensations
> De 1'AuscuIf. torn. ii. p. 700. 2 On Diseases of Arteries, page 63.
ANEURISM OF THE AORTA. 403
in the pelvic regions, and occasional suppression of urine. Two years before,
discharges of blood from the vagina took place, which recurred generally
at regular intervals of three weeks. The inferior extremities were often
swollen from cellular infiltration.
When received into the hospital, she presented the following symptoms :
countenance anxious; no pain in the head; intelligence perfect; great
debility ; position in bed elevated ; oedema of the legs and ankles ; pulse 90
per minute, full, tense, intermittent; slight muscular movements cause pal-
pitations of the heart; oppression, but no pain in the prajcordial region.
Chest is well formed; anteriorly, with the exception of the region of the
heart, it is very resonant upon percussion; posteriorly, percussion yields a
normal sound. Respiration in front, very feeble ; absent over the inferior
third of the sternum ; posteriorly, normal. Over the region of the heart per-
cussion is dull in a space, the outline of which corresponds to the form of
the pericardium, which extends downwards from the cartilage of the third
rib the length of the sternum, and laterally, on a line drawn through the nipple,
from one inch to ihe right of the middle line of sternum to the margin of left
axilla. Impulse of the heart forcible; rhythm nearly natural; first sound
roughened, having a rasping sound strongly marked opposite the cartilages
of the third rib and along the upper third of the sternum; second sound very
feeble, somewhat prolonged.
Abdomen soft, no pain on pressure. Appetite good, food generally rejected
some hours after eating; lancinating pain in the pubic region extending to
the lumbar vertebra; dyspnoea and oppression greatest at night, when she is
obliged to sit upright in bed gasping for breath. {Treatment : venesection,
cups over the precordial region, Pi I. pulv. camph. grs. iij, sulph. moiph. grs.
1-8 q. b. h., Tr. digitalis gtts. x. t. in d., milk diet.) Small portions of blue
mass and squills were subsequently given. The patient in two weeks was
apparently better — position in bed was more horizontal, the oedema dimi-
nished, sleep less disturbed, and the nightly asthmatic paroxysms less intense.
This melioration was but momentary; in a few days the symptoms recurred
With increased violence. The inferior extremities became greatly swollen;
orthopnoea was extreme, and the patient was obliged to be constantly in a
sitting posture. The impulse of the heart was now more strongly felt, the
head of the auscultator being forcibly raised when the ear was applied to
the chest ; the first sound of the heart predominated over the second, but the
latter was distinctly audible on the right margin of the sternum. Between
the cartilages of the third and fourth ribs, the rasping sound was plainly
heard, and could be distinguished along the left margin of the sternum syn-
chronous with the first sound of the heart. The distressing thoracic symptoms
were attended with agonizing pain in the womb, and with discharge of clots of
black blood from the vagina. Transient relief was afforded by venesection,
topical depletion by cups and leeches, and the exhibition of camphor and the
narcotics. Orthopnoea, however, with the utmost distress from a sense of
suffocation, became constant after the middle of January, and death took
place on the 26th of that month.
Autopsy 36 hours after death. Large frame ; moderate emaciation ; infiltra-
tion of cellular tissue of lower extremities.
Thorax. No adhesion of lungs to the pleura costalis. Lungs throughout
crepitant; vesicles of the upper lobe much dilated, from the size of a pea to
that of a hazel nut. The parenchymatous structure throughout of a dark
grey almost black colour, resembling melanosis. The bronchia contain vis-
cid dark coloured mucus without odour.
Heart much enlarged, more than double its natural size ; right cavities
more dilated than tho-e of the left; coagula in both ventricles, especially
the right. The parietes of the left ventricle measure seven-eighths of an inch
in thickness, those of the right ventricle natural. The semilunar valves of
the aorta partially ossified ; the mitral valves opake, thickened, with cartila-
ginous depositions on the free edges; semilunar valves of the pulmonary
26*
404 HOPE ON DISEASES OF THE HEART.
arteries and tricuspid valves, natural. The aorta is apparently much dilated,
and, when cut into, presents the remarkable appearance of being a double
vessel. The internal vessel is the aorta proper communicating directly with
the heart, and is nearly surrounded by another vessel of much larger
diameter, which, commencing opposite the great sinus of Valsalva, accom-
panies the aorta until it divides into the primitive iliacs and terminates in a
culde sac. The aorta communicates with the external vessel by a valvular
fissure half an inch in length, with rounded edges, which penetrates through
the serous and partly through the middle coats, and which is situated half
an inch above the semilunar valves. The external vessel has no communi-
cation with the heart except by this opening. The innominata, subclavian,
and left carotid arteries have each double orifices communicating with the
aorta and external vessel. The innominata near its mouth is divided by a
septum into two portions; the septum terminates in a semilunar edge half
an inch above the aorta. In the left carotid the appearance of double vessels
is presented for the space of two inches; each has separate openings, one
communicating with the aorta, the other with the external vessel. In the
left subclavian, on the contrary, there is no double vessel; the orifices open-
ing into the aorta and external vessel being merely formed by a valvular
septum at the mouth of the artery.1 The intercostals of the right side of the
thorax communicate with the aorta, whilst those on the left open into the
external vessel.2 The coeliac, superior and inferior mesenteries, renal, and
other arteries given off in the abdomen above the bifurcation of ibe primitive
iliacs, communicate with the aorta. The aorta is perforated by numerous
foramina, by which communication is established between it and the exter-
nal vessel. Anteriorly the external valves is composed of three coats; an
outer, which is cellular, a middle, formed of muscular circular fibres, and an
internal, which resembles the serous tissues, but is of variable thickness, and
presents various colours in different parts of its extent. The cellular coat
and the lamina of muscular fibres are continued around the posterior semi-
circumference of the aorta, where the muscular fibres uniting with the yellow
elastic tissue of that artery form in that portion of its middle coat. The
internal membrane of the external vessel, on the contrary, is reflected upon
the anterior semi-circumference of the aorta, and the two vessels are there
firmly connected by tendinous bands resembling cordee tendiness, which pass
from one vessel to the other. These bands being cut, the lining membrane
may be readily dissected up; it is of a dull white colour, semi-transparent,
and evidently takes its red and yellowish appearance from the subjacent red
fibres of the external coat and from the elastic tissue of the aorta. The
structure of the aorta in its posterior semi-circumference is normal; in its
anterior circumference the yellow elastic tissue is devoid of the external
muscular fibres ; the cellular coat is also wanting, and is replaced by the
reflected membrane of the outer vessel. Numerous ossific deposites exist in
the aorta between its serous and elastic coats, but none in the external vessel.
Immediately above the bifurcation into the primitive iliacs the external ves-
sel ceases — the red muscular circular fibres and yellow elastic coat become
firmly united in the entire circumference of the aorta, and the structure of
iliacs and that of the other arteries throughout the body present the usual
arterial formation.
Abdomen. Stomach contracted, structure normal, except near the pyloric
orifice, where its coats were thickened with carcinomatous alteration of the
muscular and cellular tissue. Small intestines natural. Several of the
mesenteric glands presented a scirrhous appearance. Jn the left kidney were
masses of half an inch in diameter, of a dull white colour, hard texture, but
without distinct striae.
1 The ductus anteriosus had evidently opened directly into the aorta.
2 This specimen of morbid anatomy was presented to the College of Physicians, at
their meeting of February 1836, and is now deposited in the Wistar Museum of the
University of Pennsylvania.
ANEURISM OF THE AURTA. 405
Uterus enlarged, double its natural size, structure hardened, presenting
in some portions when cut a white surface without any evident striae, (tissue
lardaee.) whilst other portions were evidently marked with striae of a dull yel-
low colour; in the neck, near the os tinea?, was a softened portion of cream
colour (encephaloid).
Remarks. — Having ascertained from dissection, the identity of structure of
the middle coat of the aneurismal vessel with the middle coat of the aorta,
and the intimate union of ihe two in the posterior semi-circumference of that
vessel, I was enabled to trace out the fibres, so as to prove, that this middle
coat of the aneurismal vessel was, in fact, but the outer lamina of the middle
coat of the aorta, which had been separated from its internal lamina by the
force of the blood driven through the fissure by the contraction of the heart.
As this idea was entirely novel, it became an interesting problem to ascer-
tain, whether a separation of this kind could be effected by a fluid thrown
between the lamina? of the middle coat. Experiments for that purpose were
made ; a small tube with a capillary extremity was introduced between
the laminae of this coat of the artery, and water was forced through it fiom.
a syringe in a direction parallel to the sides of the vessel. The result was,
that the middle coat was separated into three distinct laminae. Those facts
being submitted to the examinations of several distinguished anatomists,
they fully agreed with me in the idea, that the factitious vessel was the
result of the separation of the external from the internal lamina of the middle
coat, and that its internal membrane was formed by coagulable lymph,
which had simulated the appearance of a serous tissue.
Immediately after this case, the following was presented to the observa-
tion of Dr. Goddard, which tends strongly to confirm the correctness of the
character of the lesion of the aorta, and that the aneurism was formed
between the laminae of the middle coat.
Case 2. A Dissecting Aneurism, seen at an early stage, by Paul B.
Goddard, M.D., Demonstrator of Anatomy, University of Pennsylvania.
— In January, 1836, I was requested by Dr. William Harris to make an ex-
amination of the body of a woman who had died under the following cir-
cumstances. This woman, who was cook in a respectable family in this
city, was taken suddenly ill about five o'clock in the afternoon, whilst
making some exertion, and complained of faintness and oppression in the
region of the heart. Dr. Harris was immediately sent for. and caused her to
be bled, which relieved her considerably. He saw her again in the evening,
and found her weak, but observed no symptoms indicative of immediate
danger. He was called up to her, however, in the night, and found her
moribund ; death took place soon after midnight.
On examination, the pericardium was found distended with dark blood,
firmly coagulated, estimated to amount to at least eight ounces.
The heart was large and fat, but its structure was normal in every part ; the
lining membrane of the aorta presented a yellowish appearance, studded
here and there with minute ossific patches; about three fourths of an inch
from the semilunar valves a rupture was found nearly an inch in length, in
a transverse direction, which extended through half the thickness of the
middle coat. A channel led both upwards and downwards from this point,
which was produced by the separation of the laminae of the middle coat, ex-
xending in width to one half of the circumference of the artery. The upper
channel followed the arch of the aorta, and descended as far as the origin of
the right intercostal artery, leaving the aorta at the summit of the arch to
run some inches between the coats of the innominata. left primitive carotid
and subclavian. It also ran along some of the intercostals. Many obstacles
were thrown in the way of a more perfect dissection by the family, and the
distance to which it extended in the neck was not precisely ascertained.
The whole of the channel was occupied by a coagulum of dark blood.
The lower channel, which appeared to be subsequently formed, and in
406 HOPE ON DISEASES OF THE HEART.
all probability caused the death of the patient, extended from the rupture in
the internal coat to the point of junction of the fibrous pericardium with the
root of the aorta; it passed between the two, and then, by a rupture of
the serous pericardium, escaped into its cavity.
The woman was very fat, and appeared to be well formed, muscular, and
in good health at the time of the accident. Every other organ of the thorax
and abdomen was normal. The brain was not examined.
The preparation, which was obtained with difficulty, stands at the side of
Dr. Pennock's in the anatomical museum of the University.
I believe that if the rupture had not extended into the pericardium, the
woman would have lived, and an adventitious serous lining being formed
for the new channel, it would have presented, in after years, the same appear-
ance as Dr. Pennock's preparation. There is one point very remarkable.
In Dr. Pennock's case, there are seen in the angle between the new
and the old channel, on either side, a number of filaments covered with the
new serous lining and extending from the old vessel to the new ; in my pre-
paration, the same filaments exist, formed of shreds of the middle coat, but
smaller than in Dr. Pennock's, in consequence of the want of the adventitious
covering.
The occurrence of the two cases within a short time of each other, would
go to show that the accident, when well understood, will be found to
be more frequent than has been supposed.'
Case 3. Dissecting Aneurism seen at an early period, separation of the
lamina of the middle coat of the aorta to the primitive Macs, rupture into
the pericardial sac, by Dr. J. Washingto?i, New York. — This case was
identical in character with that of Dr. Goddard in the rapidity of its fatal
termination, and in the mode of death from rupture into the pericardial sac,
but the extent of the separation of the layers of the middle coat was much
greater.
The subject of the aneurism was a robust coloured woman about fifty
years of age. Her general health throughout life had been good, and
the rupture of the aortic coats took place whilst she was stooping, and
engaged in nailing down a carpet. I did not see the individual during life,
and merely made the post-mortem examination. The physician who saw
the patient soon after the accident found her without fever, with a distinct
pulse, but not such as to require blood-letting or stimulants. She was re-
ported to have suffered some slight pain and some difficulty of breathing im-
mediately before death, but her sufferings were so little when the attending
physician visited her, that he confined his treatment to the exhibition of a
dose of Castor oil.
Death took place twelve hours after the rupture, and upon making the
autopsy, it was found, that the laceration, which at first had been confined
to the inner and middle coat, had ultimately extended through the whole
thickness of the aorta, opening into the pericardial sac. The rupture began
very near the sigmoid valves, and extended spirally, so as very nearly to en-
circle the aorta — the two ends of the spiral laceration being about an
inch from each other. The laminated character of the middle coat of the
aorta was seen along this rupture ; a thin lamina of this coat being partially
separated from that portion of it which was adherent to the inner coat.
Through this spiral rupture, blood had been driven by the heart between two
layers of the middle coat of the aorta down to the bifurcation into the com-
mon iliacs, separating them in the posterior semi-circumference of the artery.
At the point of separation of the laminae of the middle coat from each other,
fibres of either layer stood out distinctly, crossing each other as tenacula
holding the two layers together. That the rupture along the extent of the
aorta was not between the outer and middle coat, but between two layers
» American Journal of Medical Sciences, November, 1838.
ANEURISM OF THE AORTA. 407
of the middle coat, the one adhering to the inner, and the other to the outer
coat, was very evident from careful dissection of the part, as well as from
the tenacula formed out of the very substance of the middle coat, and which
have been represented as apparently holding the two layers together along
the line where the separation had ceased. The inner coat of the aorta, at,
and near the place of rupture, was dotted over with atheromatous spots, but
no ossification existed ; the aorta itself was enlarged, but not aneurismal,
near its origin ; the valves were pretty sound, and the whole heart slightly
dilated ; the pericardium was gorged with blood, the opening into it from
the aorta being about the diameter of a quill.
The liver ascended to the fourth rib, and possibly contributed indirectly to
the rupture.
Case 4. Dissecting Aneurism of the Aorta, effusion of blood between the
lamincB of the middle coat, factitious canal extending to the renal arteries,
6fC, saculated aneurism throughout the arteries. — A black woman of great
age, said to be nearly 100 years old, who was a patient in the Philadelphia
Hospital in May, 1S-41, presented in connexion with general dropsy the
symptoms of great dyspnuea, often amounting to orthopnoca, constant
cough, great jactitation, inability to remain in the horizontal posture, and
was obliged to be supported upright in bed. Pulse intermittent, constipation,
urine scanty and albuminous. No accurate detail of the history of the
disease could be obtained, further, than that she had been taken suddenly
three years before with violent pain in the left breast, which, from its acute
character, was thought to be pleurisy, and that the dropsical symptoms had
existed for a vear.
The physical signs were, dulness on percussion over the inferior half of
both sides of the thorax ; marked bulging of the ribs over the precordial
region, and in a space of about four inches square beneath the sternal ex-
tremity of the right clavicle, over both of which prominences percussion
yielded a flat sound, especially marked in that of the praecordia. The im-
pulse of the heart was strong and heaving, and the apex beat in the left
axillary region beneath the fourth rib; but one sound, namely, the first,
could be heard ; this was strongly rasping, or rather roughly whizzing, re-
sembling the noise produced by the rushing of steam from the boiler of
a steam engine: this abnormal sound was so loud as entirely to mask the
sound of respiration. The roughness of the cardiac, sound was heard
loudest on the upper portion of the sternum, and along the right margin of
its upper third ; where its pilch was very high ; at the apex it was some-
what ringing.
Post-morlem.— At the examination after death, cellular infiltration was
universal ; four gallons lympid serum were found in the abdomen. Thorax.
The thorax presented the same external character as during life, and upon
opening it, the apex of the heart was found forced upwards as high as the
interval between the third and fourth left ribs, so that that organ, instead of
being in its usual oblique situation, was placed almost horizontally across
the chest. This situation was occasioned partly by the distended state of
the abdomen and by the pressure of the aneurismal tumour, subsequently
described, by which the right side of the heart was forced from its natural
situation, being driven downwards, the right auricle being nearly opposite the
right nipple. The peritoneal sac contained four ounces of citron coloured
fluid : no adhesion between the heart and pericardium. Walls of left ven-
tricle one inch in thickness, exclusive of the columnar ; ventricle dilated,
mitral valve thickened, with cartilaginous deposite ; some of the corda? ten-
dinese shortened, rendering the valve permanently open ; right ventricle and
auricle greatly dilated, double their usual size; tricuspid orifice not closed
by the valve; ventricular walls four lines thick; endocardium in both ven-
tricles thickened and opake. Aortic valve thickened, permanently open,
corrugated, and contained osseous and cartilaginous deposite ; pulmonary
408 HOPE ON DISEASES OF THE HEART.
valve very thin, and lacerated in some points near the walls of the artery.
The aorta immediately above its valve was apparently greatly enlarged, and
upon cutting into it, it was found that a laceration of two thirds of the cir-
cumference of that artery existed, penetrating the serous coat and the
internal Lamina of the middle coat, and that by the passage of blood through
this rent, the external lamina of the middle coat had been separated from the
internal layer of that tunic, and that a factitious route for a portion of the
aortic column of blood had been formed as far as the renal arteries. This
channel was lined by a false membrane simulating serous tissue, and the
exterior wall of the canal was formed of the cellular tissue common to it
and the aorta proper, the external lamina of the aortic middle coat, and the
false membrane. The aneurismal canal nearly surrounded the aorta at its
origin from the heart ; at the arch it passed spirally around the innominata
and left subclavian. Several fissures were formed through the coats of the
aorta, by which a portion of the effused blood again entered the proper canal
of that vessel; — thus, at the origin of the vessels from the arch, were two
rents, each three quarters of an inch long, one at the cceliac of one fourth of
an inch, and two others at the renal arteries of about the same length. The
internal surface of the aorta throughout its entire extent was thickly studded
with cartilaginous deposites, and many dilatations existed, not only in the
aorta, but also in the principal arteries of the body, forming numerous sacs,
varying from half an inch to two inches in length, and giving to the vessels
a peculiar knotted appearance. In the arch of the aorta were three such
sacs, one in the thoracic aorta, one at the cceliac, two at the renal arteries, —
in fact they existed at the origin of every artery in the abdomen. Upwards
of twenty sacculated aneurisms were found in different parts of the arterial
system. In all these sacculated portions of the arteries, the internal coat still
remained, except, when removed by the sharp bony formations, which were
occasionally found in them.
The liver was enlarged, cirrhosed ; the kidneys, granulated ; (Bright's
disease;) and the internal coats of the intestines congested with blood.
The preceding four cases of dissecting aneurism are all, that I know of, that
have occurred in the observation of American physicians. In all, the lesion
has been identical, viz., the separation of the laminae of the middle coat, by
blood driven by the propulsive force of the heart through a rent, caused by a
laceration of the serous coat and a partial rupture of the layers of the middle
coat. I am induced from the examination of these pathologieal specimens,
and from the fact that the attachment of the external fibres of middle coat to
the cellular is much firmer than is that of the layers of the middle tunic be-
tween themselves, to believe, that dissecting aneurism, when it occurs to
any extent, will be found to be between the lamina of the middle coat, and
not between the middle and the outer coats of the artery. — P.]
SECTION II. — Pathological effects of Aneurisms of the Aoita on contiguous parts.
The pathological effects of aneurisms of the aorta on contiguous
parts, vary according to the volume, the form, and the position of
the tumour.
Dilatation, when not very considerable, produces little derange-
ment of the surrounding parts. For, as the swelling is equable and
diffuse, it does not exert a pressure on any one organ in particular,
and its magnitude is not such as to create much inconvenience from
general infarction. The worst of its effects are those which it pro-
duces on the trachea and great bronchi ; for, though the pressure
be slight, it often suffices, in consequence of the great irritability of
these parts, to occasion considerable dyspnoea. It must not, however,
ANEURISM OF THE AORTA. 409
be imagined that dilatation is an unimportant affection. It will here-
after be shown that when complicated with enlargement of the heart,
which it generally brings on, it is one of the most formidable diseases
incident to the circulatory apparatus.
An aneurism which forms a defined tumour, whether it be of the
true, or the false species ; whether it be large, or small, may produce
the most pernicious effect. These are,
1st. Such as result from compression of the neighbouring parts.
2nd. Such as result from their destruction.
1st. By compression, the functions of the lungs, bronchi, heart and
oesophagus, are deranged, and that sometimes to a fatal extent. In
the abdomen the functional derangements are comparatively incon-
siderable, and very rarely endanger life. The reason of this is two-
fold ; first, that the abdominal organs arc not of so vital a nature as
the thoracic ; and secondly, that the tumour, instead of being pent
up in a rigid, bony case like the chest, is permitted, by the yielding
of the intestines and the distensibility of ihe abdominal parietes, to
expand freely in almost every direction. Pressure on any particular
organ, therefore, is in a great measure obviated by the want of
counter-pressure or a fulcrum. A ventral aneurism, however, even
though not much larger than an egg, when seated behind the stomach,
I have known to produce severe and obstinate symptoms of dys-
pepsia ; as anorexia, nausea, flatulence, acidity, insatiable craving,
occasional pains in the epigastric and hypochondriac regions shooting
through to the spine, constipation, and progressive emaciation. A
case of this kind was under my care last summer. Dr. Graves re-
lates a similar one in the Med. Gaz. vol. xx. p. 66. Ventral aneu-
rism, also, sometimes deranges the respiration by preventing the due
descent of the diaphragm — an effect which may proceed either from
the magnitude alone of the tumour, or, what is much more common,
from its being seated near, or in the substance of the muscle, and
impeding its motions. Ventral aneurism is also occasionally attend-
ed with involuntary evacuation of the urine and fasces, by remark-
able alternations of constipation and diarrhoea, and by deep-seated
excruciating pains, resembling those of lumbar abscess. These
symptoms arise from compression and irritation of the cceliac,
hypogastric, and other plexus of organic nerves. A deeply interest-
ing case, illustrative of this, has been published by Dr. Beatty in the
Dubl. Hosp. Rep. vol. v. p. 166.
2nd. The consequences of destruction of contiguous parts are far
more formidable than those resulting from their compression.
When the tumour exerts an unusual pressure on any organ or
texture, adhesive inflammation takes place and unites the parts in
contact. As the pressure increases, absorption and, ultimately,
perforation of the sac ensues, causing death by internal hemorrhage
as the immediate consequence. The perforation takes place either
by sloughing or by laceration, according to the nature of the mem-
brane or texture perforated. Thus, when the tumour advances to
the skin, or when it extends into a cavity lined by a mucous mem-
410 HOPE ON DISEASES OF THE HEART.
brane, it bursts by the separation of a slough which has formed upon
its most distended parts, and not by laceration. On the contrary,
when the sac projects into a cavity lined by a serous membrane,
sloughing of the membrane does not take place, but the parietes of
the tumour, having become extremely thin in consequence of dis-
tention, at length burst by a crack or fissure, through which the blood
is discharged. An aneurism may burst into a great variety of parts,
which we shall notice in succession.
When the lungs are in contact with the tumor, adhesion, absorp-
tion of the sac, and rupture of the pleura take place, and the effused
blood deluges the bronchi and causes suffocation (Case of Lafin).
I have known two other instances of this.
It often happens that an aneurism of the ascending aorta, or arch,
compressing the trachea or one of the great bronchial trunks, opens
its way into it by ulceration of the cartilaginous rings and sloughing
of the mucous membrane, and causes suddenly fatal haemoptysis.
More rarely, perforation takes place into the oesophagus, and death
then ensues from haemetemesis.
Aneurisms occasionaly burst at the origin of the aorta, and cause
death by effusion of blood into (he pericardium. The fatal event,
however, is not always so sudden as in the preceding cases ; a cir-
cumstance which Laennec attributes to the pericardium being sup-
ported, and the effusion consequently restrained, by the general
infarction of the chest resulting from the presence of the tumor.
This reason appears to me unsatisfactory, because, as before ex-
plained, aneurisms at the root of the aorta generally burst before
they attain any considerable magnitude : nor, if large, would the
resistance offered by the atmospheric pressure in the lungs equal the
force with which the blood tends to escape into the pericardium — a
force equal to the propulsive power of the left ventricle. It is, per-
haps, more probable that the inextensibility of the pericardium
beyond a certain point, and the resistance of the heart to compression,
form the principal powers which limit the effusion of blood. It
would appear that life is sometimes protracted for a considerable
period after the rupture of the sac; for, in specimens presented to
the Societede la Faculte de Medecine by M. Marjolin, the' margins
of the aperture, according to Laennec, were polished, as if of old
standing and, as it were, fistulous.1 Rupture into the pericardium
is very rare. Laennec never met with an instance. The first that
has fallen under my own observation, occurred in 1830, at St.
George's Hospital. Morgagni2 and Scarpa,3 however, have collect-
ed together a considerable number of these cases, and Hodgson saw
two, the aneurism beginning half an inch above the semilunar
valves, and occupying the whole ascending aorta and arch.
I have met with one instance of an aneuris'm at the origin of the
aorta, bursting into the right ventricle (Case of Mitchell).
Aneurisms have been known, though very rarely, to burst into the
' Laennec Op. Cit. ii. p. 715. * Epist. xxvi. Nos. 7, 17, 21.
3 On Aneurism, § xix. p. 103 et sequent.
ANEURISM OF THE AORTA. 411
pulmonary artery. MM. Payen and Zeink saw an instance,1 and
Dr. Wills another.2 My friend Professor Monro showed me a pre-
paration of an aneurismal pouch springing from the aorta directly
against the pulmonary artery ; and it is probable that, if the patient's
life had been prolonged, rupture would have taken place into the ar-
tery. His son, Dr. David Monro, favoured me with the case of Evans,
in which were two openings out of the aorta into the pulmonay
artery.
The left cavity of the pleura and the posterior mediastinum are
the parts into which thoracic aneurisms most frequently burst. It
is extremely seldom, on the contrary, that they open into the right
pleura.
Laennec has seen an aneurism of the descending aorta, which had
compressed and destroyed the thoracic duct, and produced engorge-
ment of all the lacteal vessels.
Aneurisms sometimes compress the descending vena cava, and
cause cerebral congestion, cedematous intumescence of the face, and
even apoplexy. 1 have met with several instances of this kind.
Corvisart,3 and Bertin and Bouillaud4 each cite a case of apoplexy
thus occasioned. 1 have repeatedly noticed varicose enlargement of
the veins on the sternum and upper ribs, resulting from the same
cause, and also great venous intumescence round the root of the
neck.
Another effect of aneurisms is, to obliterate arteries springing from
them, or contiguous to them. I have met with two cases in which
both the left carotid and subclavian were plugged up at their origin
from the tumor.5 The obliteration is sometimes effected, not by a
plug of lymph, but by contortion or compression of the vessel.
Mere contraction of the origins of arteries from these causes is very
common.
Ventral aneurisms may open their way into the various abdominal
viscera, as the intestines, the bladder, &c, as well as into the cavity
of the peritoneum. In a case by Dr. Beatty, and another by Dr.
StokesJ they burst into the left cavity of the pleura.
It is also stated that they may burst under the peritoneum, and
that the patient may survive for months or even years, while a suc-
cession of pulsating tumors are gradually formed in the left hypo-
chondriac, lumbar, iliac, and inguinal regions, which diminish the
impulse and murmur of the original aneurism (Dr. Cowan's Manual,
p. 43).
Aneurisms not only cause destruction of the soft parts ; but, what
is still more remarkable, erosion of the bones. This phenomenon
has been variously explained. The old pathologists erroneously
1 Bulletin de la Faculte Medecine, 1819, No. 3.
2 Trans, of Soc. for the Improvement of Med. Chirurg. Knowledge, vol.
iii. p. 85.
3 Journal de Medecine, par MM. Corvisart, Leroux et Boyer, torn. xii. p. 159.
4 Traite des Maladies du Cceur. p. 137.
1 Cases of Aneurism, vii. viii. Lond. Med. Gaz. Sept. 12, 1829, p. 449.
412 HOPE ON DISEASES OF THE HEART.
ascribed it to a chemical solvent power of the blood. Hunter, Scarpa,
and Hodgson thought that it resulted from absorption of the earthy-
matter, in consequence of the pressure of the sac. Corvisart and
Laennec attribute it to a sort of detrition or wearing down, produced
by a purely mechanical action. Bertin and Bouillaud believe that
it is more or less dependent on inflammation. To myself it appears
that absorption and mechanical detrition are the principal agents
concerned in producing the effect. That pressure is capable of ex-
citing absorption of bone, is certain, as the vertebras have been found
excavated by an aneurismal tumor without being divested of their
periosteum ;l and there can scarcely be a doubt that, when a denuded
bone is exposed to the constant dashing of a column of blood, it
undergoes disintegration by the mechanical detachment of its par-
ticles.
Whether inflammation ever contributes to the effect, is difficult
positively to determine. Analogy does not discountenance this
opinion, yet appearances are adverse to it ; as pus has never been
found on bone eroded by an aneurism ; as exfoliation scarcely ever
takes place, and as nothing is discovered on it analogous to the ci-
catrization or irregular reproduction observable in other bones when
affected with caries.
Cartilage, whether exposed to the action of the blood in aneurismal
sacs, or to the pressure alone of the tumor, either remains entirely
uninjured, or suffers incomparably less than bone. This is most
manifest in the intervertebral substance and the cartilages of the false
ribs. The circumstance is attributable to the elasticity of cartilage,
which protects it from mechanical disintegration, and to its less
highly organized structure, which renders it little susceptible of
absorption, or ulceration. The bones liable from their position to
be eroded by aneurism are, the vertebras, the sternum, the ribs, and
sometimes the ossa ilii.
It is principally by aneurisms of the descending aorta that the
vertebras are injured. In these cases, the portion of the sac in con-
tact with the vertebras is entirely destroyed, and its borders adhere
very firmly round the eroded part of the bone, on which the blood
plays freely in consequence ofthe fibrinous layers having been absorb-
ed at that part. The destruction is sometimes so deep, that the shell of
the vertebras forms the only partition between the sac and the spinal
canal. Very rarely, however, does rupture take place into the canal.
I am not aware that there are more than three instances on record ;
one by Laennec, in the Revue Medicale for 1825 ; another, of which
the preparation, by Mr. Chandler, is in the Hunterian Museum ; and
a third by Dr. Beatty, in the Dub. Hosp. Rep., vol. v. p. 188. [A
fourth case was presented to the notice of the Editor; see note at
page 396.— P.]
Ventral aneurisms seldom produce this effect, because the abdo-
minal viscera and walls yield to the tumor. When, however, the
1 Hodgson, p. 79.
ANEURISM OF THE AORTA GENERAL SIGNS. 413
tumor springs from the posterior side of the aorta, and is braced
down by the crura of the diaphragm, as in Dr. Beatty's case above
quoted, "erosion may take place : I have also seen a tumor so braced
down by the pancreas, right kidney, and pyloric end of the stomach,
— all cemented together by old adhesions, that, if the patient had
survived sufficiently long, I should think that spinal erosion would
have taken place.
When the spinal nerves are irritated by erosion, the usual neu-
ralgic and paraplegic symptoms may be experienced in the lower
extremities, as in Dr. Beatty's [and Dr. Pennock's cases.]
It is by aneurisms of the ascending aorta and arch that the ster-
num and ribs are eroded. The tumor generally presents on the right
side, if it spring from the ascending portion of (he vessel ; but if it
affect the centre of the arch or the innominata, it usually projects at
the upper part of the sternum and about the sternal ends of the clavi-
cles, which have even been dislocated from this cause. When the
tumor is connected with the posterior or descending part of the arch,
it shows itself underneath the left clavicle.
According to Hodgson, when the periosteum contributes to the
formation of the sac, its vessels continue to secrete an earthy matter,
which, in some instances, has been deposited to such an extent as
to form a considerable portion of the tumor.
Small aneurisms have the effect of destroying bones in a greater
degree than large : a circumstance attributable to the greater con-
centration of the pressure exercised by them.
SECTION III. — Signs and Diagnosis of Aneurism of the Aorta.
In the present section, the general and physical signs will be de-
scribed separately: in the next, a brief synopsis will be given of the
two conjointly, with reference to the several forms of aneurism.
General Signs of Aneurism, of the Aorta. — When an aneurism
is buried deep in the chest, and not capable of being detected by the
sight and touch, it does not present a single general sign which is
peculiar to itself, and therefore pathognomic of its existence. There
are even cases in which it occasions no functional derangement —
no inconvenience whatever ; and the first circumstance that unveils
the truth, is, the sudden death of the patient while apparently in the
enjoyment of perfect health. I have met with six or seven instances
in which large aneurisms have existed without awakening even a
suspicion in the minds of the medical attendant. One, in particular,
eluded the penetration of a distinguished foreign auscultator, though
he explored the lungs with eminent success.
There is only one general sign of aneurism of the thoracic aorta
which is unequivocal and certain: namely, a tumor presenting
externally, and offering an expansive as well as heaving pulsation,
synchronous with the action of the heart.
Of the remaining general signs, a large class are identical with
those of organic disease of the heart: viz. palpitation, dyspnoea,
cough, tendency to syncope, terrific dreams, starting from sleep,
414 HOPE ON DISEASES OF THE HEART.
haemoptysis, livid or otherwise discoloured complexion, cerebral or
hepatic congestions, serous infiltration, &c. This identity arises
from an identity of cause; namely, an obstacle to the circulation,
which depends either upon the aneurism alone, or conjointly upon
it and a disease of the heart, to which, sooner or later, the aneurism
almost invariably gives birth, if seated in the ascending aorta or
arch, but very rarely, if seated beyond those parts. I have already
shown (p. 296) that when the aneurism is unconnected with hyper-
trophy or dilatation of the heart, it may subsist for a long period,
even for years, without producing any material symptoms of an
obstructed circulation : consequently, under such circumstances,
the symptoms above enumerated will be slight or wholly absent.
But when the aneurism becomes complicated with disease of the
muscular substance of the heart, marked obstruction of the circula-
tion ensues, and the above symptoms may attain the highest degree
of intensity. From the whole argument, therefore, it results, that
as the symptoms in question are slight when resulting from aneu-
rism alone, and only considerable when it is complicated with dis-
ease of the ventricles, they are but equivocal and unsatisfactory
signs of the aneurism in particular.
There are, however, certain other general signs which are more
characteristic: yet even these are ambiguous and ansatisfactory ; as
they only bespeak lesions of the viscera, or derangement of their
functions, but do not proclaim the latent cause of the mischief. But
when they coincide with the signs derived from auscultation, they
lose their ambiguity and rise into real importance ; for the two
classes of signs, general and stethoscopic, are a commentary on each
other, and reciprocally borrow a precision and certainty of which
they are individually destitute.
I shall succinctly describe the general signs to which I refer, and
subjoin to each the principal sources of fallacy. The means of
detecting the latter, I shall point out in the final synopsis.
1. When the tumor has attained a considerable magnitude, the
cavity of the chest is preternaturally filled, and the patient com-
plains of a sense of constriction, infarction, and oppression.
But these sensations are common to almost all diseases of the
chest.
2. The radial pulses are sometimes dissimilar, or one is extinct
— an effect dependent on obstruction, or obliteration, of the arteria
innominata, or left subclavian.
But the difference of the two pulses at the wrist may proceed from
a variety of causes independent of aneurism of the aorta, as contrac-
tion of the origin of either subclavian from osseous, cartilaginous,
steatomatous, or other depositions ; obstructions in the course of the
artery, occasioned by tumors, wounds, aneurism, &c; an irregular
subdivision of the humeral, brachial, or radial artery. I have
known the most ludicrous surmises occasioned by the radial cross-
ing to the outside at the middle of the fore-arm, and the superficialis
volee supplying its place at the wrist.
ANEURISM OF THE AORTA — GENERAL SIGNS. 415
3. When the origin of either subclavian is contracted, the pulse
at the corresponding wrist is later than the ventricular systole in a
greater degree than natural, — for, in the healthy state, it is a little
later.
I have not found this symptom uniformly present under the
circumstances in question. Besides, the heart is more frequently
its source than the aorta, and I have observed it to be most con-
siderable in cases of regurgitation into the left auricle ; but obstruc-
tion of the aortic valves may occasion it in a minor degree, particu-
larly if this lesion be accompanied with attenuation or atony of
the ventricular parietes. Even dilatation with attenuation, soften-
ing, and, in short, any cause weakening the expulsion of the blood
out of the left ventricle, may give rise to it. When the sign exists
in both pulses, the presumption is strong that its source is in the
heart.
4. According to Corvisart, a purring tremour, the fre?nissement
calaire of Laennec, is sometimes perceptible to the hand at the
middle or upper part of the sternum, and indicates aneurism of the
ascending aorta.
Purring tremour above the clavicles is an almost constant con-
comitant, and therefore a valuable sign, of dilatation of the arch ;
but, according to my experience, it is unfrequently and imper/ectly
occasioned in that situation by sacculated aneurisms, especially if
lined by strata of lymph. I have never known the tremour to be
occasioned below the clavicles by dilatation, unless the enlarge-
ment was so great as to extend beyond the lateral margins of the
sternum, and allow the tremour to be felt through the intercostal
spaces: but I have met with one case in which a dilatation of the
pulmonary artery, though not voluminous, afforded a marked
tremour between the cartilages of the second and third ribs on the
left side : this, however, is not remarkable, as the artery, about an
inch and a half above its origin, naturally lies nearly opposite to
the part described, when the patient is in the horizontal position.
I have never known a sacculated aneurism create a tremour below
the clavicles, unless the tumor had eroded the bones of the chest and
presented externally, underneath the integuments; yet I can believe
that there may be cases, though I do not happen to recollect one, in
which the tremour is perceptible through the costal interspaces.
But the purring tremour may be occasioned in any part of the
chest by mucous rattles, particularly those of the snoring kind, in
the large bronchial tubes ; and I have observed that, when derived
from this source, it is a very common cause of deception with
young auscultators, in reference both to aneurisms of the aorta,
and valvular diseases of the heart. The fallacy may be effectually
avoided by simply requesting the patient to hold his breath.
5. When the trachea, or primary bronchial divisions are com-
pressed by an aneurismal tumor, a harsh wheezing or sibilous
sound, proceeding deep from the throat, characterises the respira-
tion ; the voice is either croaking, or reduced to a whisper, or it is
416 HOPE ON DISEASES OF THE HEART.
a compound of both ; respiration may be feeble in one lung, and
puerile in the other, from compression of one of the primary-
bronchi ; the breathing is often extremely laborious, and, when the
heart is simultaneously diseased, asthmatic dyspnoea sometimes
occurs in paroxysms of the most suffocating severity. When the
oesophagus is compressed, deglutition of solids is rendered difficult,
and sometimes impracticable; for the descent of the morsel excites
an excruciating pain from the summit of the sternum to the spine,
or lancinating deeply in every direction through the chest.
But compression of the trachea, or oesophagus, with the above
symptoms, may be occasioned by tumors of any description, — even
by aneurism of the innominata (Case by Dr. Stokes, Dub. Jour. v.
p. 406). Wheezing respiration may proceed from an accumulation
of glutinous mucus in the great bronchi, and it is common in all
forms of asthma. I have likewise known it produced in an extreme
degree by chronic laryngitis with thickening of. the soft parts
covering the arytaenoid cartilages, and also by ossification and
ulceration of the larynx from strumous, syphilitic, and mercurial
disease. I have also known it produced by chronic, strumous
hypertrophy of the tonsils, which in one instance occasioned suffo-
cation. So difficult was it, before the discovery of auscultation, to
distinguish the seat of wheezing respiration, that it has in many
instances been imputed to an affection of the larynx, when it was,
in reality, occasioned by an aneurism of the aorta, and, under these
circumstances, bronchotomy has several times been actually per-
formed with the view of obviating suffocation by the supposed
laryngeal affection.
6. When the vertebras are eroded, the patient suffers an intense
terebrating pain in the spine; and when the brachial plexus of
nerves is compressed by the tumor, an aching sensation pervades
the left shoulder, neck; scapula and arm, with numbness, formica-
tion, and impaired motive power of the limb.
But I have met with cases in which nearly similar pains were
experienced, although there was no destruction of the vertebras;
and it is common to hear individuals affected with rheumatism or
spinal disease make the same complaints. I have several times
met with intense neuralgia of the neck, shoulder, and arm, from
malaria, and yielding to quina and iron. Aching pain down the
inside of the arm may also be occasioned by various forms of or-
ganic disease of the heart, and it thus constitutes a part of that
concatenation of symptoms which is denominated angina pectoris.
I have likewise often met with it in hysterical females subject to
palpitation, in nervous males, in very plethoric individuals, and
occasionally in cases of pericarditis. In all these cases, the pain
probably originates in irritation of the cardiac plexus of the pneu-
mogastrie, propagated to the internal cutaneous nerves.
7. When, in consequence of an adhesion between the aneu-
rismal sac and the pleura, the blood plays upon the lungs, a sense
of ebullition is said to be experienced.
ANEURISM OF THE AORTA — GENERAL SIGNS. 417
But the same symptom is familiar to individuals labouring under
phthisis, or chronic mucous catarrh ; and it proceeds from the suc-
cessive bursting of large bubbles, formed by the transmission of
air through the fluid in tuberculous caverns, or in the greater
bronchial ramifications.
8. It occasionally happens that the patient suffers excruciating
pain from a spasm, pursuing the course of the diaphragm, and
binding the chest around, as with a cord.
This symptom is too vague to be important, and it also occurs
in hysteria, gastrodynia, colic, spinal diseases, and rheumatism of
the diaphragm.
9. A pulsation felt underneath the sternum or ribs at the superior
part of the chest.
This, although one of the least equivocal signs of aneurism, is
not without ambiguity. It may be occasioned by a tumor of any
description, as an enlarged gland, or a cancer, interposed between
the sternum and the aorta, and receiving the pulsation of the latter.
10. A pulsation is felt above the sternum or clavicles.
But this may be occasioned, 1. by enlarged glands or other
tumors seated on the subclavian artery, and receiving its pulsation.
2. By varix of the jugular vein about its junction with the sub-
clavian. In five cases, I have seen immense swelling of this kind
occasioned by encephaloid tumors of the right lung compressing
the descending cava. Both of the preceding conditions have
deceived expert practitioners. 3. By subclavian aneurism. This
affection sometimes resembles aneurism of the aorta so exactly, that
it is extremely difficult to distinguish them. Allen Burns records
a case in which all the eminent surgeons of the district were
unanimous in pronouncing the affection subclavian aneurism; yet
it proved to be aortic.1 Sir A. Cooper has published a number of
similar cases; and one is mentioned by Professor Monro tertius.2
4. By aneurism of the arteria innominata or the carotid. In April,
1826, I saw a case at Guy's Hospital, which led to much delibera-
tion respecting the propriety of taking up the carotid above a
pulsatinof tumor, supposed to be an aneurism of that artery. It
was finally decided that the tumor was too low, and the design
was judiciously abandoned. The affection proved to be a dilatation
of the aorta and arteria innominata. The carotid was sound. This
state of parts was indicated to me by the stethoscope. Mr. Hodgson
met with a similar case.3
11. The superior and middle parts of the chest are dull on
percussion. But this sign I have not found to occur, unless the
aneurism was larger than an egg ; and, moreover, it is common to
several other diseases, as encephaloid tumors of the lungs and
anterior mediastinum; hydropericardium, which, if very great,
may mount as high as the second rib; pleuritic effusion, which, if
i Surg. Anat. of Head and Neck, p. 30. 2 Elements of Anat., vol. ii. p. 249.
3 On the Diseases of Arteries, p. 90.
11— h 27 hope
418 HOPE ON DISEASES OF THE HEART.
confined to one side, may mount almost to the clavicle; circum-
scribed empyema at the upper part of the chest, — of each of which
diseases I have seen repeated instances.
12. An enlarged and varicose state of the subcutaneous veins
over the upper part of the chest, especially the sternum.
But this may be occasioned by any tumor compressing the
descending cava within the chest, of which I have seen five in-
stances from encephaloid disease of the right lung: it may also
be occasioned in a less degree by any disease of the heart which
occasions a great impediment to the circulation through the right
side of the organ.
It cannot be a subject of surprise, that a series of symptoms
liable to so many fallacies should have proved insufficient, without
the aid of auscultation, to dissipate the deep obscurity which in-
volved the diagnosis of aneurisms of the aorta.
Physical Signs of Aneurism, of the Aorta. — The investigations
of M. Laennec on aneurism of the thoracic aorta were limited and
inconclusive. Accordingly, he remarks that, " Of all the severe
lesions of the thoracic organs, three alone remain without pathog-
nomonic signs to a practitioner expert in auscultation and percus-
sion—namely, aneurism of the aorta, pericarditis, and concretions
of blood in the heart previous to death."
I shall first present the opinions of Laennec, respecting the phy-
sical signs of aneurism of the aorta, and then offer the results of
my own researches, by which I hope to make it apparent that this
malady is characterized by sufficiently pathognomonic signs.
Laennec's opinions are as follows : — On applying the cylinder, in
two instances, to tumors presenting externally, he found that their
pulsations were exactly isochronous with the pulse ; that the shock
and sound greatly exceeded those of the ventricles ; that the beating
was distinctly audible on the back, and that the second sound could
not be distinguished at all. For the last reason he denominated the
aneurismal pulsation simple, in contradistinction to that of the heart,
which has a double sound. From these two cases he felt certain
that, in some instances, pectoral aneurisms might be recognized by
the simple pulsation, usually much stronger, both in impulse and
sound, than that of the heart; but he thought that, in a larger pro-
portion of cases, the sign would be insufficient: for, as the slightest
dilatation of the heart renders its sounds audible over the whole ster-
num, and even below and along the clavicles, he imagined that,
under such circumstances, the first or systolic sound of the organ
would be confounded with the sound of the aneurism, with which it
is synchronous ; while the second or diastolic sound, being audible
as far as the tumor, would lead the anscultator to suppose that he
there heard the beating of the heart, and not that of the aneurism. I
shall presently show that this reasoning is incorrect.
As the second sound is not audible over the abdomen, Laennec
found no difficulty in recognizing ventral aneurisms by the simple
pulsation.
ANEURISM OF THE AORTA — PHYSICAL SIGNS. 419
According to my experience, the cylinder is scarcely less capable
of affording decisive indication of pectoral, than of ventral aneurism.
It is unimportant whether the pulsations be "simple" or "doable"
for, though double, they may be distinguished from the beating of
the heart, by unequivocal criteria: viz.
1st. The first aneurismal sound, coinciding with the pulse, is dif-
ferent from the first sound of the heart : it is a murmur, — varying,
indeed, in its pitch, and softer or rougher, according to the circum-
stances of each case, but still a murmur: and it is to this murmur
that the loudness of the sound is attributable, when it exceeds that
of the ventricular systole.
2. Supposing that there is no valvular disease of the heart, the
aneurismal murmur, explored from its source in the direction of the
apex of the heart, becomes progressively weaker, till, on arriving at
a point about an inch above the apex, it is wholly inaudible or very
feeble and remote, while the first sound of the heart itself, a totally
different sound, is louder at this spot than at any other. It is impos-
sible, therefore, to confound an aneurismal murmur with the first
sound of the heart in its healthy state. But supposing that it is not
healthy : supposing that it has been converted into a murmur by
valvular disease ; that murmur, as it attends the first sound, will
necessarily be seated either in the auricular valves from regurgitation,
or in the semilunar valves, from an obstruction in them or the orifice :
in which cases the diagnosis will be as follows : —
a. In the case of auricular regurgitation : If a murmur be heard
distinct and loud at the upper part of the aneurismal tumor — the part
most remote from the apex of the heart; or, in fact, at any part
above the third rib, the auscultator may rest assured that, in the
absence of semilunar murmurs, it proceeds from an aneurism, rather
than from the auricular valves; as murmurs of the latter are always
either very weak, or whollyinaudibIe,so faroff. On the other hand,
he may be assured that there is simultaneously an auricular regur-
gitant murmur, if he find it loud and near-sounding about an inch
above the apex of the heart, where the aneurismal murmur, in its
turn, is very weak or inaudible. The principle of this diagnosis is
precisely the same as of that by which semilunar, are distinguished
from auricular murmurs (p. 114).
b. If the valvular murmur be seated in the semilunar valves, the
diagnosis is somewhat more difficult, though in general practicable.
It has already been shown, (p. 114), that a murmur of these valves
is propagated two inches or more along the course of the vessel,
whether the aorta or pulmonary artery, in which it originates ; and
it has also been shown, (p. 366), that when the murmur is con-
siderably louder and on a higher key two inches or more up the
vessel, especially the aorta, than opposite to the valves, it results
from roughened coats, or dilatation, or aneurism of the vessel.
When the aneurism forms a tumor at the side of the sternum, if
the murmur is loud on the outer or humeral side of the tumor, it
may be pretty confidently referred to an aneurism ; since a murmur
27*
420 HOPE ON DISEASES OF THE HEART.
of the semilunar valves is very feeble or wholly inaudible so far
from the course of the great vessels. If an impulse on the tumor
accompany such a murmur, the evidence of aneurism is almost
positive.
3. As it has been shown in the preceding paragraphs that the
first sound of an aneurism can be distinguished from the first
sound of the heart, whether natural or with murmur, the presence
or absence of the second sound of the heart on the aneurismal
tumor is unimportant; yet even this sound can generally be traced,
with a progressive increase of intensity, either to its immediate
source, the semilunar valves, or to the line of the aorta and pulmo-
nary artery, along which and the sternum it is propagated as far as
the clavicles. The second sound of an aneurism is occasionally
attended with a feeble murmur, arising from the expulsion of a por-
tion of its blood by the elastic contraction of its walls during the
ventricular diastole. This effect would be greater during an unfilled
state of the arteries, as from general anaemia or aortic regurgita-
tion,— a state in which, as shown by Dr. Corrigan, there is a greater
flux of blood into and out of aneurisms.
Such an aneurismal murmur with the second sound, is easily
distinguishable from the murmur of semilunar regurgitation, by
the latter being audible down the course of the ventricles, and by
its being exceedingly prolonged ; namely, through the whole dias-
tole and period of repose : neither of which circumstances obtains in
the aneurismal murmur.
This murmur, again, cannot be confounded with an auricular
murmur attending the second sound, because the latter, when it
exists at all. (which I find to be exceedingly seldom.) is always too
feeble to be audible in the situation of an aneurism.1
A few remarks may now be made on the character of the aneu-
rismal murmur with the first sound ; as it is in general rather
peculiar, and therefore distinctive. It is a deep, hoarse tone, of
short duration, with an abrupt commencement and termination,
and often, but by no means invariably, louder than the most con-
siderable murmurs of the heart. It accurately resembles the rasp-
ing of a sounding-board, heard from a distance ; whereas the sound
occasioned by valvular disease of the heart is less hollow and more
prolonged, with a gradual swell and fall. The depth and hollow-
ness of the tone is generally greater above the clavicles than below ;
which is probably attributable to its being reverberated through the
chest before it arrives at the ear. This probability is countenanced
by the following considerations: a. That, in several cases with
1 In the first edition of this work, some obscurity crept into the diagnosis
of the aneurismal sounds, in consequence of its being then unknown that the
closure of the semilunar valves was the cause of the second sound. Since
this was demonstrated by my experiments, (p. 48 et seq.,) the author of the
Rational Exposition (now called The Pathology and Diagnosis of Dis-
eases of the Chest) has made several unsound criticisms on my original
mode of diagnosis, but he has not had the ingenuity to supply its defects.
ANEURISM OF THE AORTA — PHYSICAL SIGNS. 421
which I have met,1 while the sound, above the right clavicle, was
loud and hoarse, it was merely a whizzing without hoarseness, on
the superior part of the sternum, where the dilated ascending aorta
was in apposition with the bone, and where, consequently, the
sound was transmitted immediately to the ear. b. That, in the
heart, when we listen to its sounds directly through the solid parts
where they are uncovered by lung, morbid murmurs are less hoarse
and hollow than those occasioned by pectoral aneurisms, c. That,
in aneurisms of the abdomen and extremities, where there is little
or no reverberation of sounds, there is still less degree of hoarse-
ness and loudness.
The abruptness of theaneurismal sound, compared with the pro-
longed, swelling character of ventricular murmurs, is owing to the
latter being generated by a gradual muscular contraction, or a pro-
longed semilunar regurgitation, while the former is due to the sudden
propulsion of a fluid through a vessel naturally very resistant, and
rendered still more unyielding by disease ; or through an abrupt
orifice into a sac, which enjoys little latitude of motion.
The loudest aneurismal sound is that occasioned by dilatation :
and it has more of the grating or rasping character, in proportion as
the interior of the vessel is more overspread with hard, and especially
osseous asperities. When the dilatation is confined to the ascending
aorta, the sound, impulse, and purring tremor above the clavicles,
are stronger on the right, than on the left side; and the sound along
the mesial part of the sternum — the tract of the ascending aorta, is
often superficial, and of a whizzing character.
Old aneurisms, the parietes of which are thickened by fibrinous
depositions, yield only a dull and remote sound. In all cases of dilata-
tion, and in the majority of sacculated aneurisms, the sound is loudest
above the clavicles, even though the impulse be stronger below.
In some cases of the sacculated species, it is louder on the side of the
neck opposite to that where the tumor exists. I have found this to
proceed from one or other of two causes — first, disease of the inner
coat of the aorta before or beyond the tumor, and opposite to that
side of the neck where the sound was loudest; secondly, the inter-
position of the sac, thickened with fibrinous layers, between the aorta
and the superclavicular region, in consequence of which the source
of sound, — the mouth and cavity of the sac, was unusually remote
on the side occupied by the tumor. In one case, where the aneu-
rismal murmur was barely audible, I found the tumor interposed
between the sternum and the origin of the aorta, pushing the latter
upwards of three inches back. The weakness of the sound was there-
fore owing partly, no doubt, to the remoteness of the aperture into the
sac, but partly also to the inexpansibility of the tumor itself occa-
sioned by its osseous case in front.
The sound of aneurisms is in most instances audible on the back;
1 See, for instance, cases of aneurism of the aorta, Lond. Med. Gaz., Sept,
12, 1829, case 9.
422 HOPE ON DISEASES OF THE HEART.
and when the tumor occupies the descending aorta, and is extended
along the spine, it is often louder behind than on the breast. If it
possesses, on the back, the abrupt, rasping character, the evidence
which it affords is almost positive ; for the loudest sounds of the
heart, when heard on the back, are so softened and subdued by dis-
tance, as totally to lose their harshness.
Dr. Corrigan has shown, as already stated, that, cceteris paribus,
the murmur and tremor of an aneurism are stronger during the lax
state of the arteries resulting from anaemia or aortic regurgitation ;
because there is a greater flux of blood into and out of the aneurism,
and greater latitude for vibration both in the fluid and the walls of
the sac, than when the vessels and the tumor are completely and
tightly distended.
Purring tremor is another characteristic of the aneurismal pul-
sation. It is more considerable in simpledilatation than in sacculated
aneurism, particularly if the former be accompanied with much
asperity of the internal membrane. From numerous dissections, the
fact appears to me to admit of the following explanation : — in cases
of dilatation, the interior of the vessel is almost invariably rugged
from steatomatous, osseous, cartilaginous, or other adventitious de-
positions ; and the blood, in permeating such a tube, necessarily
occasions a strong tremor, as its particles are thrown into preter-
natural commotion and collision, not only by the enlargement of the
calibre of the vessel at the dilated part, by which they are diverted
from their direct course, but also by the roughness of the surface of
the vessel, by which they are reflected in endless conflicting currents
from its sides. In sacculated aneurism, on the contrary, though a
portion of blood descends into the sac, and may there create a tremor
if the amount and velocity of the current be sufficient; yet the
greater quantity pursues a direct and tranquil course along the smooth
canal of the artery ; and the tremor is therefore less considerable.
It is rarely occasioned at all by old aneurisms ; because, in conse-
quence of their magnitude and the thickening of their sacs with
fibrinous coagula, they possess little susceptibility of vibration.
Purring tremor proceeding from organic disease of the aorta, may
easily be distinguished from that occasioned by anaemia. The for-
mer is constant even during a tranquil state of the pulse ; it is restric-
ted to a limited space above the sternal extremities of the clavicles,
and is accompanied with the hoarse aneurismal sound. Anaemic
purring tremor, on the other hand, is only accasional, occurring
when there is palpitation from nervous or physical excitement ; it
extensively pervades the adjoining arteries, the concomitant sound
is comparatively soft and feeble, and it is always attended with the
venous murmur in the jugulars.
Pulsation attends every species of enlargement of the aorta. In
dilatation, it exists above the sternal ends of the clavicles only, and
always on both sides of the neck simultaneously; though, when
the enlargement is confined to the ascending aorta, it is stronger on
the right than on the left side. When dilatation is of a pouched
ANEURISM OF THE AORTA — PHYSICAL SIGNS. 423
form, and of great magnitude, it may occasion pulsation under the
sternum. Of this I have met with instances. Carotid and subcla-
vian aneurisms produce impulse, sound, and tremor on the affected
side only, and by this circumstance they may easily be discriminated
from aortic enlargements.
In sacculated aneurism seated in the upper parts of the chest,
pulsation exists both above and below the clavicles, but I have
generally found it stronger below. When the tumor is large, and
occupies the left extremity of the arch, the impulse is often percep-
tible from the sternum to the left shoulder, and as low down as the
third or fourth rib. When it lies in contact with the ribs posterior-
ly, the shock is sometimes felt on the back. This, however, is a
rare occurrence.
Dulnesson percussion is always found over aneurisms consider-
ably larger than an egg, lying in apposition with the surface.
I searched during ten years for an aneurism immediately behind
the heart, with the view of ascertaining whether the presence of this
organ in front would or would not disguise the aneurismal impulse
and murmur, and render the physical diagnosis impossible. A case
at length occurred in St. George's Hospital, which led me to the
discovery of a new presumptive sign. The post-mortem appear-
ances were as follows : — The descending aorta, from an inch below
the left subclavian down to the diaphragm, was enlarged into an
aneurismal sac, which lay across the spine, and projected, on the
right sidj, about three inches beyond the vertebrae, without reaching
the ribs: while, on the left, it extended to the ribs, had caused
destruction of three and caries of two more, and at last formed a
considerable tumor on the back. The pericardium was adherent
to the sac. Several of the dorsal vertebras were extensively ab-
sorbed. A tract down the front of the sfic was formed by the re-
mains of the aorta, a% good deal loaded with steatomatous deposi-
tion.
:i The heart was slightly enlarged, the left side being a little
thickened, while the cavities of the right side were enlarged, with-
out any increase of muscular substance" (see the Autopsy, drawn
up by my colleague, Mr. C. Hawkins, in a work on Dropsy, by Dr.
Seymour, p. 15).
The physical signs of this case may be analysed under the several
heads of, 1. murmur; 2. dulness on percussion with deficient res-
piratory murmur, and 3. impulse.
1. The patient was under observation in the hospital for a year.
I examined him, for the first time, six months before death. No
aneurismal murmur was ever heard by myself or others, either in
the precordial region or on the back : this sign therefore failed. It
does not follow, however, that it would fail in every case; for its
absence in the present instance might have been referable, not to
the interposition of the heart, rendering it inaudible, but to the size,
thickness, and configuration of the sac, preventing, as they some-
times will do, the generation of the murmur, — a view which is the
424
HOPE ON DISEASES OF THE HEART.
more probable, because no murmur was audible on the tumor even
after- it had protruded posteriorly through the ribs. In other cases,
similar circumstances preventing the generation of a murmur might
not exist: we should, therefore, in all cases, explore for this import-
ant sign.
2. On my examination alluded to, six months before death,
when there was yet no external tumor, I found dulness on percus-
sion, and deficient respiratory murmur, along the left side of the
spine ; and Dr. Kingston (who was the first "to whom, long before
my examination, the idea of aneurism occurred), had, I believe,
observed the same, several months before. Now, as the patient
had neither previously had pleurisy, nor then presented the usual
physical signs of fluid in the chest ; and as he had never had
peripneumony to occasion hepatization of the lung, nor then pre-
sented any symptom of tubercular consolidation, it followed that the
dulness on percussion and deficient respiration were referable to a
tumor of some kind ; and considerable pain in the precordial region,
and through to the spine, rendered it probable that the tumor was
an aneurism, — but not more than probable; since encephaloid
tumors in the lungs may create the whole of the same signs ; of
which I have seen several instances.
3. The impulse of the heart was exceedingly vigorous, and was
double, consisting of a diastolic, as well as a systolic impulse, each
of a jogging character; so that the whole impulse might be called
a double jog. All the auscultators who saw this case, were agreed
that there must be considerable hypertrophy of the heart to account
for so strong an impulse: a different opinion, indeed, would have
been irrational and unwarrantable, as being opposed to all anterior
experience respecting the physical signs of hypertrophy. Yet,
as above reported by Mr. Hawkins, the organ was found only
"slightly enlarged and thickened."
Now, this strong and double-jogging impulse, in the absence of
adhesion of the pericardium, and of displacement of the heart to
the front of the spine, constitutes the new sign of aneurism, or at
least of a tumor, behind the heart, to which I allude. I say, " in
the absence of adhesion of the pericardium," because, in the first
edition of this work, I pointed out the same double-jog as a new
sign of adhesion (see back, p. 199); and I say, "in the absence of
displacement of the heart to the front of the spine," because this
also occasions the double-jogging impulse (see Displacements).
The three classes of cases corroborate and throw light upon each
other, because they all admit of the same explanation : for as, in
adhesion of the pericardium binding the heart down to the spine,
and in displacement of the organ to the front of the spine, the
ventricles are tilted forward as often as the rounded swell of their
body, during the systole and diastole, encounters the resistance of
the spine; so the same occurs when an aneurismal or any other
tumor behind the heart is the cause of the resistance. It may.
therefore, be stated, in conclusion, that in the absence of adhesion,
ANEURISM OF THE AORTA SYNOPSIS OF THE SIGNS. 425
and of displacement, a strong, double-jogging impulse affords pre-
sumptive evidence of a tumor behind the heart, the aneurismal
nature of which must be determined by the concurrence of other
signs of that affection. If there be a murmur in the praecordial
region distinctly not referable to a valve ;— still more, if there be
no murmur whatever in the praecordial region, yet one audible on
the back, the evidence of aneurism afforded by this sign, in con-
nection with the double jog of the heart and the posterior dulness
on percussion, is almost positive. In the absence of murmur, the
signs would not warrant more than presumptions of aneurism, as
an encephaloid or other tumor behind the heart might occasion the
signs.1
While this is passing through the press, I find that Dr. Todd
mentions having " himself observed, some years ago, a case where
the heart was pushed forward and outwards, and, as it were, com-
pressed against the ribs, by an enormous aneurism of the thoracic
aorta." He makes no remark on the signs, except that u the sounds
of the heart were so modified by this compression as to lead to the
erroneous diagnosis of concentric hypertrophy." I can easily
believe that, if the compression be very great, the sounds may be
diminished ; for, in my first experiments on the denuded heart of
the ass, I found that heavy pressure with the stethoscope on the
ventricles, invariably diminished the sounds — of course, by curbing
the contractions of the organ and the extension of the valves. It
remains, therefore, to be ascertained by further cases whether
diminution of the sounds will prove to be a constant sign of an
aneurism behind the heart occasioning great pressure.
SECTION IV. — Synopsis of the Physical, in conjunction with the General Sign?, in
reference to the several varieties of Aneurism of the Aorta.
Simple Dilatation of the Arc/i, and ascending- Aorta.
Pliysical Signs. — 1. A constant pulsation above both clavicles
at their sternal ends; stronger on the right side if the enlargement
1 It was supposed by some non-auscultators, that the strong action of the
heart in the above case was occasioned by the mere obstacle presented to
the circulation by an aneurism at a distance: also, that the absence of
dropsy was a proof of aneurism, and of the heart being sound; because, said
they, the violent action, if from enlargement, would have been attended
with dropsy, whereas aneurism presents so little obstacle to the circulation
as not to create dropsy. These statements are contradictory; for if an
aneurism presented so little obstacle to the circulation as not to create
dropsy, it would not. for the same reason, excite strong impulse of the
heart: or, reversing the proposition, if it could occasion strong impulse of
the heart, it would, for the same reason, excite dropsy. The facts, however,
are incorrect: auscultators know that a remote aneurism, though it may
occasion palpitation on exertion, does not morbidly increase the impulse of
the heart except by slowly giving rise to hypertrophy: also, that hyper-
trophy, with violent impulse, may in some cases exist for years without
occasioning dropsy, and that, therefore, nothing more than remote presump-
tions can be drawn from the presence or absence of dropsy in such a case
as the present.
426 HOPE ON DISEASES OF THE HEART.
is confined to the ascending portion, and never communicated to
the sternum or ribs, unless the dilatation be enormous.
[Percussion, aloDg the margins and over the upper third of the sternum,
yields a dull sound to a greater extent than is usual, provided that no emphy-
sema of the lungs exist near that portion of the chest. — P.]
2. A hoarse rasping murmur, synchronous with the pnlse, above
both clavicles, of brief duration, commencing and terminating ab-
ruptly. If the enlargement is confined to the ascending portion3
the sound is louder above the right than above the left clavicle ;
and, along the tract of the aorta up the sternum, it is superficial,
and often of a hissing or whizzing character ; by which, and by
the murmur being loudest high up the chest, it is distinguishable
from that of diseased aortic valves. It is usually distinct on the
back, where the ventricular sounds, if audible at all, are very obscure.
3. A purring tremor above the clavicles, but never below. It is
stronger, and the concomitant sound more grating, in proportion as
the interior of the aorta is more overspread with hard, and especially
osseous inequalities.
General Signs of Dilatation. — Frequently none. When any
exist, they are a slight degree of those common to all organic dis-
eases of the heart, viz. the signs of an embarrassed circulation.
They may assume a most aggravated aspect when dilatation be-
comes complicated with organic disease of the heart.
Fallacies: and Methods of detecting them.
a. Anaemia from any cause, (especially in nervous, delicate
females,) during arterial excitement, sometimes occasions an im-
pulse and bellows-sound above the clavicles; but they may be dis-
criminated by the impulse being feebler, and the sound more a brief
whirl, than in aneurism of the aorta, and by the absence or compa-
rative feebleness of purring tremor. It is, in fact, in the subclavian
and carotid arteries that the phenomena take place ; for, though the
aorta be under the same circumstances of excitement, its action is
not so violent as to extend in any appreciable degree to the supra-
clavicular regions.
b. Aortic regurgitation, particularly when accompanied with
much hypertrophy of the heart, I have in many instances found to
occasion the impulse and whiffing sound above the clavicles in a
still more remarkable degree than anaemic palpitation. The phe-
nomena depend upon the unfilled state of the arteries and the sud-
denness and energy of the ventricular contraction — a subject
already considered (p. 123). They may be distinguished by the
sound being more whiffing and less hoarse, and-the arterial impulse
more jerking, than in dilatation of the aorta; but the best criterion
is, to ascertain the existence of aortic regurgitation, which may
always be done with certainty by the rules given at p. 323.
c. Dilatation of the pulmonary artery is a third, though ex-
tremely infrequent source of fallacy ; for the mode of detecting it I
refer the reader to the next head : viz.
ANEURISM OF THE AORTA — SYNOPSIS OF THE SIGNS. 427
Dilatation of the Pulmonary Artery.
Physical Sig?is. — I have met with one case (Weatherly) in which
this artery was dilated to the extent of five inches in its internal
circumference. It presented the following physical signs, which
have not hitherto; I believe, been noticed. The case of L. P. pre-
sents the same, but the patient is living, and the anatomical proof is
therefore deficient.
1. A pulsation with purring tremor between the cartilages of the
second and third ribs on the left side, and thence in a decreasing
degree downwards, but not appreciable above the clavicles. Also a
slight prominence between the same ribs.
2. An extremely loud, superficial, harsh, sawing sound, audible
above the clavicles and over the whole precordial region, but loud-
est on the prominence between the second and third ribs.
The general Signs were those of hypertrophy and dilatation of
the heart, which accompanied the dilatation of the pulmonary artery.
Diagnosis from Dilatation and Aneurism of the Aorta. — Dila-
tation and aneurism of the ascending aorta are perhaps the only
affections for which dilatation of the pulmonary artery could be mis-
taken. The signs, however, of the latter are so characteristic that,
with due attention, I think it scarcely possible to commit an error.
Namely, a pulsation between the cartilages of the second and third
ribs could not possibly be occasioned by a mere dilatation of the
ascending aorta ; as thisartery, even when dilated, is situated too far
to the right to extend beyond the margin of the sternum. Again, a
sacculated aneurism of the ascending aorta could not reach the car-
tilages of the second and third left ribs without being large ; and in
this case it would present dulness on percussion, and form a much
greater tumor externally than existed in the present instance. The
sound also of such an aneurism would be on a low key, and as if
remote, instead of loud and superficial. Finally, a dilatation or an
aneurism of the ascending aorta or arch would occasion a pulsation,
murmur or tremor above the right clavicle or on the right side of
the sternum, or above both clavicles, — which was not the case in the
instance of which we speak.1
Sacculated Aneurism, of the thoracic Aorta.
Physical Signs. — 1. A pulsation both above and below the cla-
vicles, but usually stronger below. If the tumor occupies the ascend-
ing aorta, its impulse is most perceptible on, and to the right of the
sternum. If it is seated in the commencement and middle of the
arch, it produces an impulse above and below the right clavicle and
about the top of the sternum, often with a visible intumescence of
the parts. If it is seated in the commencement of the descent, the
1 Dr. Stokes describes an aneurism ;' about the size of a goose's egg, which
caused a rlattish tumor extending from the second to below the third rib. and
yielded a pulsation between the second and third left ribs." Here the simili-
tude to dilatation of the pulmonary artery stopped; for there was not any
bruit de sou ffltt or de rape (Dub. Jour. v. p. 419).
428 HOPE ON DISEASES OF THE HEART.
pulsation and swelling incline to the left side, and sometimes reach
even to the shoulder. If it occupy the descending aorta, it is sodeeply
buried behind the lungs that impulse is never, to my knowledge, per-
ceptible in front; but when the tumor becomes very large and extends
backwards to the ribs, it may occasion dulness on percussion and
deficient respiratory murmur, — most frequently along the left side
of the spine, (see case at p. 422,) and, when erosion of the ribs has
taken place, an external pulsating tumor may become perceptible.
This, however, is very rare. In front, the pulsation of an aneurism
is always stronger on the tumor, than at some point intermediate
between it and the heart, and generally stronger than the impulse of
the heart itself.
2. The abrupt murmur described under dilatation, but weaker and
softer, or less rasping. In large, old aneurisms it has a dull and remote
character, and is sometimes louder on the side of the neck opposite
to that where the tumor is situated. It is generally audible on the
back ; and, when the tumor occupies the descending aorta, it is often
louder behind, especially on the left side of the spine, than in front.
Yet it is sometimes totally absent behind. If, on the back, it has
more of the abrupt, raspingsound than the ventricular systole in the
precordial region, the evidence of aneurism is almost positive.
This diagnosis of aneurisrnal from valvular murmurs is given at
p. 419.
3. A purring tremor above the clavicles. I have never found it
below, unless the tumor had penetrated through the ribs or ster-
num; yet I can suppose that a tremor might be perceptible through
the intercostal spaces, without erosion of the bones. It is weaker
than in dilatation, and in old and large aneurisms often becomes
extinct. It may be perceptible on the back, near the spine, when
an aneurism of the descending aorta has reached the ribs and occa-
sioned an external tumor.
General Signs of Sacculated Aneurism. — Any or all of the fol-
lowing signs may be present. A pulsating tumor, presenting
externally, and sooner or later causing livid redness of the integu-
ments ; deficient resonance on percussion, and defective respiratory
murmur of the part; a sense of retraction of the trachea, with a
wheezing respiration and a croaking or whispering voice ; dyspha-
gia ; an intense gnawing or terebrating ,pain in the spine ; aching
of the left shoulder, scapula, neck, axilla, and arm, with numbness,
formication, and impaired motive power of the limb; a sense of
weight and infarction in the chest; venous intumescence round the
root of the neck, and enlargement of the sternal veins; difference
of the two pulses: a strong, double-jogging impulse of the heart
when the tumor is immediately behind it (see p.. 424); some of the
ordinary symptoms of organic disease of the heart in a slight de-
gree, but very seldom dropsy.
Fallacies, and the Methods of detecting them. — Pulsation be-
neath the sternum and ribs, occasioned by amplified glands or other
tumors in the anterior mediastinumj by hydropericardium, by en-
ANEURISM OF THE AORTA SYNOPSIS OF THE SIGNS. 429
larged heart, or, finally, by adhesion of the pericardium, may, ac-
cording to my experience, be easily discriminated from aneurismal
pulsation by the following criteria.
a. Pulsating glands or other tumors in the anterior medias-
tinum are not attended with the aneurismal sound, or only in a
slight degree ; no impulse and tremor are felt above the clavicles ;
and symptoms of a disturbed circulation either do not exist at all,
or do not correspond in severity with the magnitude of the appa-
rent disease.
b. Hydropericardiwm, instead of producing the gradual, steady,
and powerful heaving of an aneurism, occasions an undulating
motion, of which some of the shocks are stronger than others, and
none are exactly synchronous with the sound of the ventricular
systole. The undulatory impulse is strongest in the left proscor-
dial region ; whereas the impulse of an aneurism of the ascending
aorta or arch is situated either on the right side of the sternum or
near the top of the sternum and the clavicles on either side, and is
notably stronger on the tumor than in the intermediate space.
Hydropericardium is not productive of the aneurismal sound. Its
history is different from that of aneurism, the latter being very
often referred to some injury, or excessive exertion, suddenly fol-
lowed by faintness, pain, and dyspnoea.
c. An enlarged heart produces an impulse which is strongest
at the apex, and decreases progressively on receding from it : the
beating of an aneurism is stronger on the tumor than at some point
intermediate between it and the apex of the heart ; and in most
instances it is stronger even than the beating of the heart itself.
Hence an aneurism distinctly conveys the impression of there
being two centres of motion — the tumor and the heart ; while the
pulsation of an enlarged heart is felt to be referable to one alone.
Finally, the ventricular contraction of an enlarged heart produces
an ordinary sound, but is not attended with aneurismal murmur, or
pulsation above the clavicles. I have never known adhesion of
the pericardium to occasion a pulsation which could be mistaken
for aneurism, until it had occasioned enlargement of the heart, its
ordinary consequence. In this case the diagnostic symptoms are the
same as those of enlargement of the heart, with one difference, that
the motion is of a more unsteady, double-jogging, and struggling
character.
d. Varix of the jugular veins above the clavicles, is distinguished
by the absence of sound and impulse, and by the compressibility of
the tumor. It must not be forgotton, however, that intumescence
of these veins, sometimes with immense, springy swelling round the
root of the neck, is a sign of a tumor compressing the descending
vena cava, and that the tumor may be an aneurism. I have
repeatedly seen the swelling result from this cause, and five times
from encephaloid tumors of the right lung.
e. Enlarged glands, or other tumors, above the clavicles, receiv-
ing pulsation from a subjacent artery, rarely occasion sound; an
430 HOPE ON DISEASES OF THE HEART.
if any exist, it is a feeble whizzing, such as is produced by com-
pressing an artery with the edge of the stethoscope. Both it and
the pulsation are confined to the side affected. If the tumor can be
grasped, it will be felt not to dilate laterally during the ventricular
contraction, and if it can be raised from the subjacent artery, its
beating and the whiff will cease entirely.
f. Subclavian and carotid aneurisms occasion pulsation, sound,
and purring tremor on the affected side alone, and these signs are
more superficial and distinct than in aneurism of the aorta. The
sound, from not being reverberated through the chest, resembles
that of a small hand bellows, instead of having the hoarseness of a
forge bellows.1
g. Purring' tremor of the chest, proceeding from mucous rattle,
may be recognised by its ceasing when respiration is suspended.
Sacculated Aneurism of the Abdominal Aorta.
Physical Signs. — 1. A constant, swelling pulsation of extraor-
dinary power.2 It appears much stronger to the ear resting on the
stethoscope than to the hand. The instrument may be forced down
in various directions into close proximity with the tumor, and an idea
of its position and dimensions may be thus obtained. By the stetho-
scope and hand together, it may be readily ascertained that the lateral
dimensions of the tumor are distinctly greater than those of the healthy
aorta ; also, that the lateral is generally equal, or nearly so, to the
forward swell; further, that the tumor is fixed, though compres-
sible, and is commonly of a more or less rounded form.
There are exceptions, however, which should make us cautious
in deciding positively against the existence of aneurism by the
1 Dr. Stokes describes a very interesting case of an aneurism of the inno-
minata equalling a " large cocoa nut, and in a great part filled with large
fibrous and laminated coagula" (Dub. Jour. v. p. 413). He states that it yielded
no bruit de sovfflet or rape. This assimilates with the principles above de-
veloped (p. 421) ; that large fibrinous coagula prevent the murmur. He adds,
that the aneurism yielded a " double sound perfectly analagous to that of the
excited heart." If this was not a kind of murmur, it must have been the beat
of the heart, transmitted through the aorta and the sternum to the tumor.
The disease caused obliteration, not only of the right carotid and subclavian
arteries, but of the jugular veins and venae innominate, and induced hemi-
plegia. The case is principally interesting, however, as having produced
several symptoms usually confined to enlargement of the aorta ; namely, dys-
phagia, stridulous respiration, very feeble respiratory murmur of the right
lung, and puerile of the left, from compression of the right bronchus; also,
dulness on percussion, at first confined to the sternal end of the right clavicle,
but eventually pervading the '; antero-superior fourth of the right side, the upper
third of the sternum, and the sternal fourth of the Uft clavicle."
The descent of so large a tumor into the chest easilv accounts for all the
symptoms. The diagnosis would be formed with least**difficulty in the early
stage; namely, by noticing where the disease commenced. Without this
knowledge, it would be almost impossible, in the advanced stage, to distin-
guish such a tumor from an aneurism of the aorta.
2 Dr. Stokes has correctly explained the prodigious pulsations of large
aneurisms over their whole surface ©n the principle of the hydrostatic balance.
ANEURISM OP THE AORTA — SYNOPSIS OF THE SIGNS. 431
absence of any of the preceding signs. In the cases already alluded
to, by Dr. Beatty, and Dr. Pennock, a very large aneurism above
the coeliac artery occasioned no perceptible tumor or impulse, in con-
sequence of being braced down and pressed backwards by the crura
of the diaphragm. I lately attended a case in which there was
little or no lateral swell and impulse in consequence of the tumor
being braced down by old and firm adhesions of the pancreas
across it, and of the kidney on its right side. In St. George's Hos-
pital, about four years ago, was a case of a perfectly moveable, pul-
sating, and compressible tumor, which proved to be an aneurism of
the caeliac artery.
2. Dulness on percussion will be perceived if the tumor be large
and superficial; but if it be of moderate size or small, (e. g. less
than a cricket-ball), I have found that the dulness is neutralised, or,
at least, rendered obscure, by the resonance of surrounding or
superincumbent intestine, especially if charged with flatus. A pur-
gative, by removing flatulence, will often render the dulness more
distinct.
3. A brief and abrupt bellows-sound, not so loud or hoarse as
that of aneurisms in the chest. It is sometimes audible on the back,
but not so often as in pectoral aneurisms. I have, in several cases,
heard the murmur loudest at that part of the tumor which I found
after death to correspond with the opening into the artery. The
murmur is very much limited to the seat of the aneurism, and, from
being- propagated downwards with the stream in the aorta, it is more
audible below than above the tumor.
The murmur is occasionally absent. I found this to be the case
in the instance above alluded to, of an aneurism, about as large as a
turkey's egg, bound down by firm adhesions of the pancreas and
right kidney. I presume that the adhesions prevented the murmur
partly by restricting the influx of blood, and partly by thickening
the walls of the sac and rendering them unsusceptible of vibration.
Dr. Corrigan has devised an ingenious expedient by which a
murmur may often be developed in an aneurism, which did not
previously exist: namely, by placing the patient in the horizontal
position, or even with the abdomen raised higher than the chest.
This position, by removing hydrostatic pressure, diminishes the dis-
tention of the sac, and consequently permits a freer flow of blood into
and out of it ; and it is by the inward current that the murmur is
occasioned. This device is especially useful in incipient, small
aneurisms, before a pulsating tumor is distinctly perceptible. I
imagine that great inexpansibility of the sac may prevent its suc-
cess; for, in my case above described, the murmur did not exist,
though the patient was placed horizontally, and was also anaemic,
with a pulse of 102. Dr. Corrigan's sign is not to be depended
upon alone ; because most anaBmic subjects yield a murmur when
in the horizontal position (see p. 148).
A murmur created by the pressure of the stethoscope on a super-
ficial artery over the tumor, must be carefully distinguished from a
432 HOPE ON DISEASES OF THE HEART.
murmur of the aneurism itself. This source of fallacy existed in
my case above referred to, and I decided that it was superficial by
the nearness and hissing tone of the sound, by its being restricted to
one spot, and by its ceasing whenever the artery was obliterated by
firm depression of the stethoscope. It was found after death to have
proceeded from the superior mesenteric artery, which descended
over the summit of the tumor, and was as large as a quill.
The second sound of the heart is generally inaudible on the
abdomen, and, consequently, the pulsation is simple. This, how-
ever, is a point of little importance.
The physical signs now described, present so many exceptions,
and so many other sources of fallacy remain to be noticed, that we
must always be slow and circumspect in deciding on the existence
of abdomitiat aneurisms. There are some cases in which it is impos-
sible, without violating the principles of sound inductive reasoning,
to give a positive diagnosis. We must then wait and watch.
General Signs. — They are those of slightly impeded respiration
dependent on an imperfect descent of the diaphragm ; of dyspepsia ;
of lumbar abscess, with or without caries of the vertebras and symp-
toms of spinal pressure ; of renal disease; and of pressure on the
nerves or viscera of the abdomen and pelvis ; but none are patho-
gnomonic of aneurism, except a pulsating and usually compressible
tumor, felt through the abdominal parietes.
Fallacies, and Methods of detecting them.
a. A scirrhous or encephaloid tumor of the stomach, internally
or externally.
b. Enlargement of the liver extending across the epigastrium, —
which is very common.
c. Enlargement of the pancreas by hydatids, or scirrhus — ex-
tremely rare affections.
d. Fungoid or other tumors of the mesentery, omentum, transverse
arch of the colon, or diaphragm, which are pretty common.
e. Indurated faces, air, intestinal concretions, or masses of tape-
worm, impacted in the transverse colon.
It is the common property of all these tumors, when they rest
upon the aorta, to-- receive its pulsation, and in many instances to
occasion a bellows-murmur by compressing the vessel, — especially
when the tumor is pressed down upon it by the stethoscope. Not
many years ago, almost every pulsating tumor in the epigastric and
umbilical regions was assumed at once to be an aneurism; but
modern experience has shown that the great majority are nothing
more than the tumors above enumerated. They may generally be
discriminated from aneurisms by the following.circumstances : —
I. The impulse, with few exceptions, is comparatively feeble ; for
the elevation of a tumor by the aortic impulse, is not equal in degree
or force to the expansion of an aneurismal sac. Diffuse, superficial
tumors, as the left lobe of the enlarged liver, I have found to trans-
mit the impulse more feebly than smaller tumors sitting immedi-
ately on the aorta, as an enlarged pancreas.
ANEURISM OP THE AORTA — SYNOPSIS OF THE SIGNS. 433
2. The impulse is still more feeble, and sometimes impercep-
tible, when the stethoscope is applied laterally; since aneurisms alone
present a considerable lateral expansion. When the tumor can be
displaced by lateral pressure, so as totally to lose its impulse, (espe-
cially if the aorta can then be felt to be of its natural size.) the evi-
dence against aneurism is almost positive. If, after the displacement,
the impulse continue undiminished, an aneurism of the cceliac, its
branches, or the superior mesenteric artery, may be suspected. The
enlarged liver yields no lateral impulse. The lateral impulse is best
examined by inclining the patient a little to the opposite side, while
he lies in the horizontal position.1
3. The tumor, when connected with the stomach, colon, or omen-
tum, is often superficial, and moveable with the movements of these
viscera, so as to lose all impulse, both lateral and direct.
4. A few brisk purgatives of calomel, colocynth, and aloes, will
often remove indurated faeces, intestinal concretions, and flatulence,
and thus dissipate the tumor and impulse. The same remedies, fol-
lowed by ounce doses of ol. Terebinth, pur if., will often produce
a similar effect on masses of tape-worm.
5. Tumors, if solid and firm, are more incompressible than the
generality of aneurisms: yet this sign is of little value, because many
tumors, as the encephaloid and flatulent varieties, are very springy
and compressible; while, on the other hand, I have several times
found aneurisms wholly incompressible, in consequence either of the
thickness of their sacs, or of the firm adhesion of the pancreas, kid-
neys, crura of the diaphragm, or other contiguous parts.
6. In cases of enlargement of the liver, dulncss on percussion ex-
tends, loithout any interval, from the right hypochondriac region and
scrobiculus cordis, over and beyond the seat of the pulsation; and the
outline of the viscus may finally be traced with the fingers. Except
in reference to the liver, dulness on percussion must not be too much
trusted; as it may result from other solid tumors besides aneurisms,
and it may be absent or indistinct in aneurisms of small, and even
moderate dimensions, in consequence of the resonance of superincum-
bent or surrounding intestine.
7. The murmur of an ordinary tumor is generally less than that of
1 Professor Harrison of Dublin states that he has met with, or seen, aneu-
risms of the cceliac, hepatic, splenic, gastric, and mesenteric arteries, of the
left gastro-epiploic, the coronary of the stomach, the right spermatic, and the
left renal capsular (Dub. Jour. v. 436).
Dr. Stokes met with an aneurism of the hepatic artery, the size of a large
orange, and pressing directly on the bile duct. It was covered by the capsule
of Glisson and by the pancreas, which encircled its lower half. He did not de-
tect any pulsation in it. and he ascribes the absence of the phenomenon to the
want of counterpressure beneath. The tumor and the enormously distended
gall-bladder had, within a brief period, protruded the liver downwards, im-
parting to it the aspect of great enlargement (Dub. Jour. v. p. 402). The
same protrusion occurred in Dr. Beatty's case of aneurism (Dub. Hosp. Rep.
y.) These facts are worth recollecting in reference to the diagnosis of ob-
scure diseases of the liver.
12 — a 28 hope
434 HOPE ON DISEASES OF THE HEART.
an aneurism, being only a slight whiff, like that produced by com-
pressing an external artery; and it may often be suspended by ap-
plying the stethoscope laterally and pushing the tumor off the aorta, —
which is not the case with an aneurismal murmur. It must not be
forgotten that an artery running over any tumor may create a super-
ficial murmur when the vessel is compressed with the stethoscope.
Such a murmur, therefore, must not hastily be considered aneurismal.
8. Collateral evidence for, or against aneurism, is sometimes af-
forded by the history and general symptoms. Thus, malignant
disease in other parts, with general cancerous cachexia, would afford
presumptions that an abdominal pulsating tumor was malignant.
Existing and previous hepatic derangement would countenance the
view of enlargement of the liver. Though derangement of the sto-
mach and bowels, with constipation, flatulence, gnawing pain, &c,
would direct the attention to those organs; yet such signs are
treacherous, because it has been shown that an aneurism, by irritating
the cceliac plexus and other abdominal nerves, may occasion the ut-
most degree of functional disturbance. If the patient be young, as,
for instance, under set. 20 or 30, of healthy constitution and family,
and have never experienced sudden and great faintness and dyspnoea,
with or without pain, after any considerable corporeal exertion, as
running, ascending a hill, lifting, straining, rowing, gymnastics, &c,
the presumptions are against aneurism; and vice versa.
Cases must be considered doubtful when the signs are partly
those of aneurism, and partly of an ordinary tumor. The following
case will exemplify how many important signs of aneurism may be
absent, yet the disease exist. A gentleman in Scotland, whom I saw
in consultation with Dr. Abercrombie, and Drs. Munro and Chisholm
of Inverness, presented a rather strongly pulsating tumor in the epi-
gastric region. He was under set. 28, and of remarkably healthy
constitution and family, and could not recollect to have felt suddenly
ill after corporeal exertion. There was scarcely any lateral expansion
and impulse; no murmur, even in the horizontal position, except the
whiff of a superficial artery, created at pleasure, in one spot, by pres-
sure with the stethoscope; no distinct dulness on percussion; no pain
in the epigastric region or back, except a little occasionally, and at
long intervals of weeks or months; no disturbance of the circulation,
— for, a month before I saw him, he had ascended a high mountain
in an unusually short time; pulse 100, with emaciation and anaemia,
since cerebral convulsions and active treatment a fortnight before
my visit; no signs, physical or general, of disease of the heart or
lungs, and they were ultimately found healthy. There were severe
dyspeptic symptoms, with constant craving, constipation, often bilious
evacuations, and emaciation, — symptoms which .had existed for about
a year and a half, and which seemed to point rather to a tumor con-
nected with the stomach, bowels, or pancreas, than to an aneurism.
Opposed to these symptoms, so little indicative of aneurism, stood
the single, but important sign of a rather strong, direct pulsation of
the tumor, — a pulsation, however, not stronger than I have seen
ANEURISM OF THE AORTA. 435
from ordinary tumors. Under these circumstances, it was agreed
that the symptoms did not justify a positive opinion, that the case
should be considered doubtful, that it would be necessary to wait and
watch, and that, meanwhile, the treatment should be conducted on
principles embracing both views.
The patient died a fortnight afterwards, from rupture of the aneu-
rism, and extravasation of five pints of blood into the cavity of the
abdomen. The post-mortem appearances, to which I have several
times alluded, fully explained the symptoms, or, rather, the want of
them. The sac (exclusive of external coagula formed after its rup-
ture) was three inches long by two broad; and it sprang from the
right side of the aorta, by an aperture as large as a shilling, half an
inch below the coeliac artery. The deficiency of lateral pulsation
was attributable, not only to the moderate dimensions of the sac, but
also to extensive, old adhesions of the pancreas on the left and front
of the tumor, and of the kidney on its right, which firmly bound it
down. The absence of murmur was referable to the limited expan-
sibility of the tumor, resulting from the same causes; and these also
accounted for the patient's capability of great exertion, without ap-
parent inconvenience, so late as six weeks before his death. The su-
perficial whiff proceeded from the superior mesenteric artery, which
crossed the summit of the tumor. The absence of dulness was re-
ferable to the stomach, constantly distended with flatus, being ad-
herent by its pyloric extremity to the most prominent part of the
tumor. The absence of all but slight and occasional pain was ac-
counted for by the uninjured state of the spine. The dyspepsia was
connected with mamellated thickening of the mucous membrane of
the stomach from chronic inflammation, probably excited by the irri-
tation of the tumor.
The absence of so many important symptoms of aneurism, strongly
evinces the necessity for caution in all such cases. The only safe course
is, to adhere rigidly to the rules of inductive reasoning, and never to
draw positive conclusions from evidence which is merely presumptive or
equivocal. If the practitioner allow vague impressions and undefined
convictions to divert him from this course, he cannot fail to commit
occasional errors in diagnosis, of which the patient, no less than his
own reputation, may have to pay the penalty; for the latitude in diet,
exercise, &c. which might be admissible in the case of ordinary tu-
mors, would be destructive in aneurism; while the restrictions una-
voidable in the latter, would often be detrimental to the general
health in the former. By treating an equivocal case as doubtful, till
it has declared itself, both extremes may be avoided.
Anaemic and nervous Pulsation of the Jlbdominal Aorta. — The illus-
trious father of auscultation ascribed this phenomenon to nervous and
hysterical irritability, with spasm of the aorta; but I have shown that
anaemia — a deficient, or too watery state of the blood, is its most
essential constitutional cause, while nervousness, whether pre-existent
or consequent, co-operates by accelerating the circulation. (See Inor-
ganic Murmurs.)
436 HOPE ON DISEASES OF THE HEART.
This is a very frequent and deceptive affection, leading the unwary
to the supposition of aneurism. When, says Laennec, it exists in
conjunction with air, pent up in the colon or duodenum, and pre-
senting the feel of a compressible tumor, the resemblance to aneurism
is still more complete. The aortic throb will also increase the pul-
sation of any solid tumors resting on the aorta, as described under
the preceding head. After an examination of many cases, I am satis-
fied that, in the absence of immovable, solid tumors resting on the
vessel, attention to the following circumstances will render the dia-
gnosis easy.
Physical Signs. — The cylinder may be pressed down on the aorta,
so as to yield a distinct feel of the vessel of its natural calibre. The
sphere of its pulsation is limited transversely, but extensive longitu-
dinally, being usually more or less perceptible from the epigastrium
to the bifurcation. The impulse, instead of being the gradual, steady,
and irresistible heaving or expansion of an aneurism, is a smart,
though vigorous jerk; and the sound, when any exists, is merely a
short whiff, distinguishable by its shortness from venous murmur,
and audible along the whole course of the vessel, instead of being
loudest at one spot, as in aneurism. Dr. Graves has shown that it
may sometimes be excited by the horizontal position, when, from
hydrostatic pressure, it does not exist in the erect. Inorganic mur-
murs and thrill, with a jerking pulse, in the carotid and subclavian
arteries, and venous murmurs in the jugular veins, generally coexist
with aortic pulsation, and serve to corroborate the diagnosis.
The general symptoms are anaemic, nervous, or hysterical; and the
pulsation and murmur are of an inconstant character, increasing and
diminishing with the exacerbations and remissions of the arterial ex-
citement.
Aortic Pulsation from Enteric Inflammation. — This has been pointed
out by Dr. Stokes. « There is," says he, " a pulsation of the abdo-
minal aorta or its immediate vessels, which is symptomatic of inflam-
matory disease in the digestive system, and which a long experience
enables me to say may be considered an important assistance in dia-
gnosis. A throbbing, generally commensurate with the disease; re-
moved by treatment calculated to relieve enteric inflammation, and
aggravated by everything which will increase this affection. In
other words, we may have, from enteritis or peritonitis, a throbbing
of the abdominal aorta or its vessels, perfectly analogous to the mor-
bid action of the radial artery in whitlow, or of the carotids or tem-
poral arteries in cerebritis." The cases in which he has most fre-
quently observed this symptom, are those of the gastro-enteric fever
of Ireland; also, in cases of fever after corrosive poisoning, where the
pulse was almost absent at the wrist; and in .peritonitis, where no
pulse could be felt. In several instances, this want of proportion be-
tween the action of the radial, and the abdominal arteries, combined
with fever, was the principal indication of enteric disease. He has
found the increased action extend along the iliac, to the femoral ar-
teries (Dub. Jour. v. p. 438). I have not yet had an opportunity of
ANEURISM OF THE AORTA. 437
verifying these observations so extensively as I could have wished;
but I think them deserving of much attention, both because they are
consistent with analogy, and because they emanate from so accurate
an observer as Dr. Stokes. One precaution would be requisite:
namely, as many of the febrile cases in question are anaemic, it would
be necessary to make sure that the pulsation was not merely anaemic,
rather than inflammatory.
APPENDIX TO ANEURISM OF THE AORTA.
I have met with a case in which an aneurismal pouch of the aorta
burst into the right ventricle; and Dr. David Monro of Edinburgh
has favoured me with the particulars of another case, in which a di-
lated and diseased aorta burst into the pulmonary artery. As such
cases present peculiar signs, and as their diagnosis has not, to my
knowledge, been hitherto explained, I need no apology for intro-
ducing them here.
Case of an Jlneurismal Pouch of the Aorta bursting into the Right
Ventricle (Fig. 21). — John Mitchell, set. about 25, baker, admitted
into the Westminster Hospital, where I saw him, October 21, 1837,
by the politeness of Dr. Roe, and Mr. Thurnam, the resident apothe-
cary. Pie stated that he had felt perfectly well till nine weeks pre-
vious to my visit; when, on lifting a sack of flour, he felt a " creak in
the heart," and became faint and very pale.1 Though " very ill,"
he continued at work for three or four days; when he gave up and
got bled. A fortnight after the accident he entered the hospital.
I made the following notes on the day of my visit. Face slightly
bloated, and of purplish or venous tint; legs very ccdematous; hands
slightly; pulse 80, singularly "jerking," especially in the carotids.
I think I have never felt a pulse equally jerking. It was like a hard
ball, forcibly shot through the vessel. Does not complain of pain.
The effort of drawing his flannel waistcoat over his head caused
shortness of breath, and intermittence and irregularity of the pulse?
for two or three minutes.
Physical Signs. — Dulness on percussion over an extent of about
three inches in diameter, extending nearly up to the third rib.a A
marked, superficial purring tremor over the upper portion of the dull
part, most perceptible about two inches from the sternum, in the
intercostal space. At the same part, there is a superficial, very loud
sawing sound, like a whispered r — more intense during the systole
of the ventricles; also a slighter second whizz accompanying the
second sound. Moreover, there is a continuous rumble, through
ivhich the other two murmurs are heard. These sounds are audible,
1 See p. 202 for instances of rupture, with similar symptoms: also, the case
of Williams delineated in Fig. 13.
2 Mr. Thurnam found the dulness and tremor ascend to the second rib. This
was probably because he examined him in the horizontal position, whereas my
examination was made in the semi-erect position.
28*
138 HOPE ON DISEASES OF THE HEART.
but less distinctly, over nearly the whole remainder of the dull part.
No purring tremor or murmur above the clavicles; the second sound
is there very feeble — indeed barely audible, and the first is wholly
inaudible. Impulse of the heart not materially increased.
The treatment was principally diuretic. The anasarca increased
to a great amount, and the patient died about three weeks after my
visit.
Diagnosis. — This case was so singular, that I could only give
doubtful and conditional diagnosis. I conjectured that a valve or
chorda tendinea had been ruptured by the lift, this being denoted by
the "creak in the heart," and the sudden paleness and fainting. I
felt certain that there wTas free regurgitation out of the aorta; as it
was positively indicated by the peculiarly jerking pulse, by the
whizz with the diastole, over the semilunar valves, and by the al-
most complete extinction of the second sound above the clavicles,
denoting that reaction on the aortic valves was defective. Mitral re-
gurgitation was also indicated by the loudness of the first murmur
near the apex of the heart. The continuous rumble and the strong
tremor, however, remained to be accounted for; and as I had once
seen these signs occasioned, in pericarditis, by friction of lymph and
churning of a moderate quantity of fluid (case of Jones), I thought
the same might be the case in the present instance, assuming endo-
pericarditis to have been excited by the rupture. Though the exis-
tence of aneurism was possible, there was no direct proof of it; and,
if it existed, it was under some new combination of circumstances;
as the continuous murmur is foreign to ordinary aneurisms.
Autopsy. — The right cavity of the chest contained several pints
of serum, by which the heart was displaced to the left side. Little
serum in the left cavity. Two or three ounces of clear serum in the
pericardium, and a few scattered patches of recent lymph on its sur-
face, which were easily peeled off with the back of a scalpel (Peri-
carditis). Heart of natural size and thickness. Mitral valve thick-
ened and opake; its chordae tendinese thickened and shortened, one
being nearly as thick as a crow-quill. Aortic valves similarly thick-
ened, but in a less degree: both presented recent, florid granulations
or vegetations (Endocarditis). The aorta, immediately above its
valves, was dilated into an aneurismal pouch as large as a small hen's
egg, which presented directly forward towards the mouth of the
right ventricle, where it formed a tumor, opening, by two apertures
on its summit, into the cavity of the ventricle, immediately below
its valves (See Fig. 21, e). One aperture was as large as an average
pea; the other, half the size. The origins of two of the pulmonic
valves were separated about a quarter of an inch, in consequence of
the interval having been stretched by the subjacent aneurism. The
valves, therefore, necessarily admitted of regurgitation.
Remarks.— I should explain the signs of this case as follows:
The systole of the left ventricle caused regurgitation through the
aneurismal apertures into the right ventricle, — the resistance in this
direction being less than that offered by the aortic circulation. The
ANEURISM OP THE AORTA. 439
simultaneous systole of the right ventricle expelled a stream, which
was not only tilted forwards by the aneurismal tumor, but encoun-
tered the stream of regurgitating blood already playing directly for-
wards against the front of the right ventricle, near its mouth: — which
part, being thus thrown into strong vibration, yielded the purring
tremor; while the agitation and friction of the blood occasioned the
concomitant loud, superficial, sawing sound. These phenomena were
the most intense about two inches to the left of the sternum, between
the third and fourth ribs, because the mouth of the right ventricle
was displaced thither by the fluid in the right cavity of the chest.
Such being the explanation of the phenomena during the ventricular
systole, we next proceed to the diastole. During this, there was a free
regurgitation from the aorta, through the aneurismal apertures, into
the right ventricle; and also from the pulmonary artery, through the
interval between the origins of the two pulmonic valves seated on
the aneurism. The two streams thus met and wrere directed forward
against the front of the right ventricle, by exactly the same circum-
stances as during the systole: hence the murmur and tremor were
maintained, though with less intensity, during the diastole also. The
natural second sound was almost extinct, 1st. because the reaction
of the aortic blood on the semilunar valves wras enfeebled by the
aneurismal regurgitation: 2d. because the regurgitation between the
pulmonic valves prevented the due expansion of those valves also.1
Such was what occurred during the ventricular diastole. But there
was, farther, a continuous rumble, occupying all the intervals be-
tween the systolic and diastolic murmurs. This appears to me to
have been occasioned by the aneurismal regurgitation being incessant;
the predominant pressure, first, of the left ventricular contraction,
and, next, of the aortic reaction being in incessant operation.
The state of the mitral valve verified the diagnosis of regurgitation
through it.
The following case, obligingly given to me by Dr. David Monro
of Edinburgh, strongly corroborates the preceding.
Case of Rupture of a Dilated Aorta into the Pulmonary Artery. —
James Evans, aet. 24, a porter, admitted into the Edinburgh Infir-
mary Oct. 30th, 1833. Accustomed, from his profession, to lift
heavy weights. Had a severe attack of acute rheumatism about ten
years ago. About ten months ago had an attack of pneumonia,
which yielded to copious depletion. To this he ascribed his symp-
toms: viz. palpitation, dyspnoea, followed, three months before ad-
mission, by swelling of the abdomen and lower extremities, which
has gradually increased.
1 This is one of the best pathological cases that I have met with, to prove
that the semilunar valves are the cause of the second sound. Had^one set of
the valves only been disabled, the second sound, produced by the other set,
would have been distinctly heard near the clavicles, where it is transmitted
unobscured by any murmur which might conceal it nearer the valves. But in
this case both sets of valves were almost incapacitated: accordingly, the sound
was almost extinguished at the clavicles,
440 HOPE ON DISEASES OF THE HEART.
On admission, the following were the symptoms. Great dyspnoea,
amounting to orthopncea; abdomen much distended, and fluctuation;
lower extremities swollen and tense; countenance tumid, and some-
what livid; great general uneasiness; action of the heart, tumultu-
ous; diffused over a large space, not strong; cough with expectora-
tion; pulse large, harsh, and thrilling, 112. Physical Signs. — Much
dulness on percussion in the precordial region. First sound accom-
panied by a loud soufflet, audible over the whole fore part of the chest,
and on the back on both sides of the spine, but most distinct at the
middle of the sternum. Second sound short, and much obscured by
the first, (hence it appears that a continuous murmur extended from
the first, over the second sound.)
The treatment employed, viz. digitalis, calomel, and squills, had
the effect of reducing the pulse and increasing the quantity of urine;
but produced no impression on the symptoms.
His general uneasiness continued, though temporarily relieved by
a small bleeding. The pulse became intermittent some days before
death, which happened a fortnight after admission.
Autopsy. — Much anasarca. Chest. Several pounds of serum in
both pleurae. Heart, enveloped in the pericardium, occupied a great
part of the left side, displacing the corresponding lung. It was found
to be more than twice the natural size, pale, flabby, and blunt towards
the apex. All the cavities were much dilated, together with the cor-
responding orifices. The walls of both ventricles retained their na-
tural thickness. All the Valves healthy, excepting the semilunar at
the mouth of the aorta, which were thickened. The Aorta itself,
from its origin to the arch, was dilated into a large, irregular sac,
which adhered firmly to the pulmonary artery, and communicated
with it by two openings, situated an inch and a half from the valves;
—the largest, capable of receiving the point of the little finger; the
smaller, of transmitting a crow-quill. The edges of both were regu-
lar, round, and cartilaginous. Nearer the arch, a third small opening
was discovered, with thin, rugged edges. The internal membrane
of the dilated portion of the aorta was reddened and rugous, from
numerous cartilaginous patches, which had advanced in some parts
to ossification.
Remarks. — The two foregoing cases correspond in the following
particulars. 1. A lift was the immediate cause of the symptoms,
though disease of the aorta had preceded.
2. Pulse pre-eminently jerking; for such was evidently the " large,
harsh and thrilling" pulse of Dr. Monro's case.
3. A loud, superficial murmur with both sounds, incessant in one
case, and apparently so, judging from Dr. Monro's description, in the
other.
4. A livid, venous tint of the complexion.
5. Great, rapid, and universal dropsy.
From these data, I should consider the following to be the patho-
gnomonic signs.
Sigyis of Aneurism of the origin of the Aorta opening into the Right
DIAGNOSIS OF ANEURISM OF THE AORTA. 441
Ventricle. — Physical Signs. — 1. A remarkably loud, harsh, superficial,
sawing murmur with both the systole and diastole, together with a
continuous, incessant rumble; both most audible above the level of the
fourth rib, on or near the sternum, and thence, along the tract of the
pulmonary artery, up to the interspace between the second and third
rib. (Great care should be taken to ascertain whether the heart is
displaced to either side by fluid or other causes; as this was the main
source of obscurity in the case of Mitchell.)
2. A purring tremor in the same situations. It would perhaps not
be very perceptible between the third and fourth ribs, if the heart
was not displaced, the base of the right ventricle being naturally a
good deal covered by the sternum; but, by causing the patient to lie
inclined towards his left side, and thus displacing the heart, the tremor
would, I have no doubt, become imperceptible. It would, of course,
be more marked when the lung, a bad conductor of sound and tremor,
is displaced from the anterior surface of the heart by hydropericar-
dium (as in Mitchell's case) or by enlargement of the organ.
3. Weakness or extinction of the second sound, near the clavicles,
in consequence of the reaction of the aortic blood on the valves being
enfeebled by the regurgitation. If both sets of semilunar valves hap-
pened to be implicated, (as in Mitchell,) the sound might be almost,
or wholly extinguished.
General Signs. — 1. Pulse pre-eminently jerking, in consequence
of free regurgitation out of the aorta.
2. Great, rapid, and universal dropsy, resulting from general ve-
nous retardation, occasioned by the pressure of the aortic circulation
being thrown on the right ventricle, and constituting a formidable im-
pediment to the transmission of its blood.
3. A livid, venous complexion, partly from the cause last specified,
and partly from a proportion of arterial blood being delivered to the
lungs, to the exclusion of an equal quantity of venous: whence the
total amount of arterialized blood in the system is diminished.
4. If the symptoms followed a lift or effort, producing sudden
faintness and paleness, the evidence would be stronger.
Signs of Aneurism of the Aorta opening into the Pulmonary Artery. —
Physical Signs. — 1. A very loud, superficial, sawing murmur, pro-
longed continuously over the first and second sounds (and probably
weaker during the interval of repose:) loudest along the tract of the
pulmonary artery.
2. A purring tremor in the pulmonary artery, in the interspace
between the second and third ribs.
3. The second sound weakened at the clavicles,
General Signs. — 1. The jerking pulse.
2. Great, rapid, and universal dropsy.
3. A livid, venous tint.
4. The circumstance of the symptoms having followed an effort,
would afford corroborative evidence.
Diagnosis of Aneurism of the Aorta opening into the Right Ventricle or
the Pulmonary Artery, from other Diseases.— -Dilatation of the Pulmonary
442 HOPE ON DISEASES OF THE HEART.
Artery presents a murmur with the first sound only, and the pulse is
not jerking. The complexion is not livid, and dropsy may not su-
pervene for years (see case of Weatherly, exemplifying all this).
Contraction of the Pulmonic Valves with Regurgitation (ex-
tremely rare). A loud, superficial murmur attends each sound; also
purring tremor; but there is no continuous murmur in intervals, and
the pulse is not jerking (case of Rogers).
Contraction of the Aortic Valves with Regurgitation. — A mur-
mur with each sound; but not nearly so loud or superficial, from the
aorta being more deeply seated; no continuous murmur; little or no
purring tremor; pulse jerking; complexion not livid, and dropsy
may not supervene for years.
Jin aneurismal passage from the origin of the Aorta into the
Left Ventricle.1 — Pulse is jerking. A murmur might attend each
sound, the first being occasioned by disease of the aorta or its valves,
and the second by regurgitation through the passage; but the mur-
murs could not be incessant, because the regurgitation could only
exist during the diastole; nor would they be so loud and superficial
as in the above cases.
Congenital contraction of the pulmonary orifice, and a common
opening of the right and left ventricles into the aorta, below its
valves. (Case of Mary Collins. See Malformations). — A very loud,
hissing, superficial murmur with the first sound only, loudest about
the middle of the sternum, over the affected orifices: pulse not jerk-
ing, but very small and weak. I have met with two other cases of
cyanosis (still living) similar to this, except that in one — Master R.
— the second sound was accompanied with a very slight filing mur-
mur from regurgitation.
Friction of lymph with churning of a little fluid in the pericardium;
also inflammatory disease of the aortic and mitral valves, with re gurgitation
through both. (See the remarkable case of Jones.) — -Here, there
was a murmur with both sounds, a continuous rumble, a purring tre-
mor and a jerking pulse; but the rumble and tremor (which I ascribe
to the rubbing and churning of the lymph and fluid) were equally
diffused over the whole front of the ventricles, and were less distinct
up the pulmonary artery; no lividity, and little dropsical tendency.
SECTION V. — Spontaneous Cure and Medical Treatment of Aneurism of the Aorta,
and Treatment of Nervous Pulsation.
Previous to entering upon the treatment of aneurism of the aorta,
we shall advert to the mechanism by which its spontaneous cure is
effected; as the reader will thus be better enabled to understand the
principles on which the treatment is founded.
The movement of the blood within the sac being retarded, partly
by the roughness of its internal surface, and partly by the fluid being
i See " Real Aneurism of the Heart," p. 312, for cases of this kind.
ANEURISM OF THE AORTA — TREATMENT. 443
withdrawn from the direct channel of the circulation, coagulation
takes place, and fibrine is deposited and organized in successive strata,
until the cavity is at length completely filled. The sac, being then
no longer exposed to the distensive pressure of the circulation, tends
to contract by its own resilience and the compression of the incum-
bent parts, partial absorption of its contents takes place, and the
aneurism is finally reduced to a small, dense, flesh-like tumor. In
arteries of the second, and inferior orders, the coagulum generally
extends to, and obliterates the calibre of the vessel itself;1 but this is
rarely the case in the aorta, as the force of the circulation in so great
a vessel prevents the lodgement of coagula. Instances, however, of
obliteration of the aorta by fibrine when its coats were diseased, are
not without example: an important case has been published by Pro-
fessor Alexander Monro,3 and Dr. Goodison describes another.
It is principally in false and mixed aneurisms that the cure by de-
position of coagula takes place. In true aneurism, and in dilatation,
such a cure is very rare; for, the walls being unbroken and smooth,
and the aperture of communication with the sac being in general
large, the blood is seldom arrested to such a degree as to deposit la-
mellated coagula. When, however, the whole circumference of an
artery is converted into a bony cylinder, there is a great tendency to
its obliteration by a plug of fibrine. Dr. Goodison's case was of this
description, and I have more than once seen the same in arteries of
the second order.
Hence, as the formation of coagula within the sac is the principal
means employed by nature in effecting the cure of aneurisms, the
primary object of medical treatment is, to promote the deposition of
coagula; and we now proceed to consider the means by which this
may be best accomplished.
The antiphlogistic treatment, rigorously pursued, acquired great
celebrity as the most efficient remedy for aneurism of the aorta,
under the designation of the treatment of Albertini and Valsalva.
By detraction of blood and spare diet they reduced their patients to
so extreme a state of debility that they were scarcely able to raise
their arms from the bed. Morgagni reports3 that when Valsalva had
taken away as much blood as was requisite, he made it a custom to
diminish the quantity of meat and drink more and more every day,
till he proceeded so far as to allow only half a pound of pudding in
the morning, and in the evening half that quantity, and nothing else
except water, and this also within a certain weight. After he had
sufficiently reduced the patient by this method, so that from weak-
ness he could scarcely raise his hand from the bed, in which he lay
by Valsalva's order from the very beginning of the disease, he increased
the quantity of aliment by degrees every day until the necessary
strength returned. Pelletan, who followed this treatment, sometimes
i Vid. Hodgson, Jones, Farre. Bailie, Petit, Desault, Scarpa.
2 Observations on Aneurism of the Abdora. Aorta by Professor Monro, Ed.
p. 5 and 8, 1827.
3 Epist. xvii. art. 30.
444 HOPE ON DISEASES OF THE HEART.
allowed two basins of broth in twenty-four hours, and lemonade as a
common drink. Laennec recommends the energetic employment
of the treatment of Valsalva (torn. ii. p. 742).
In the first edition of this work I pointed out the numerous diffi-
culties which surrounded this treatment, and showed that it was only
applicable to a very limited number of cases. Further observation
since that time has served to increase my conviction both of its dan-
ger and its inefficiency. In persons of very feeble constitutions, it
is utterly inadmissible; since it might be directly fatal by inducing
irremediable sinking, or indirectly, by establishing a state of anaemic
debility, from which the patient could never afterwards completely
rally. When organic disease of the heart complicates the aneurism,
the treatment is equally inadmissible; since excessive blood-letting is
apt to induce alarmingly protracted, and sometimes immediately fatal
syncope. The treatment, again, could not have a curative effect on
any aneurisms except those of the false, or the mixed species, —
namely, by rupture of the arterial coats; or, if of the true species,
such as have a sac so deep, and with so narrow a neck, as to be con-
siderably removed from the direct current of the circulation; for in
scarcely any others do laminated coagula form, whatever be the mode
of treatment employed.
Even in the few cases which remain after the abstraction of the
above, I strongly doubt whether the treatment really promotes the
coagulation of blood within the sac. After a certain amount of blood-
letting in healthy, vigorous constitutions, reaction is induced,— a phe-
nomenon which, by producing an inordinate activity of the circula-
tion, counteracts the desired effect of the depletion, and increases,
instead of diminishing, the pulsation of the tumor. Of the reality
of this reaction I can entertain no doubt, both from extensive obser-
vation on the human subject, and also from the experiments on dogs
described at p. 122. In these animals, bleedings, repeated daily or
every other day, occasioned, after three or four abstractions, the most
violent arterial throbbing. Even in weakly individuals, who have
not sufficient constitutional vigour to give rise to much violence of
reaction, the circulation is, notwithstanding, accelerated by the anae-
mic state induced by the bleeding, and the pulsation of the heart and
of an aneurism is correspondingly increased. In both classes of
patients — the robust and the weakly, the blood, after repeated abstrac-
tions, becomes very serous, of a pale crimson, instead of the natural
dark venous colour, contains only one-sixth to one-twelfth of the
natural proportion of crassamentum, and has sometimes a whitish
cream on its surface after standing twelve hours. As such blood con-
tains only a very small proportion of fibrine and red globules, it is
ill adapted for the formation of fibrinous coaguja; and this circum-
stance, in connexion with the increased pulsation of the tumor at-
tending the anaemic state, appears to me to afford the strongest rea-
son for believing that the treatment in question is pernicious, rather
than salutary. It may be fairly questioned, indeed, whether the
treatment of Albertini and Valsalva has ever really merited the re-
ANEURISM OF THE AORTA — TREATMENT. 445
putation which it acquired. For, as the diagnosis of aneurisms of
the aorta was involved in deep obscurity until the last ten or fifteen
years, it is pretty certain that many cases reported as cured, were
really not aneurisms, but other tumors, or anaemic and nervous pul-
sation of the aorta, simulating that disease. This is probably one
strong reason why the treatment in question has been unable to main-
tain its ground. But there is another; namely, its severit}7. Though
patients will submit to rest and extreme abstinence, they have rarely
fortitude enough to permit the superaddition of blood-letting. The
practitioner, on the other hand, has seldom the courage to insist
upon it, knowing that it is not exempt from danger, and that it will
not necessarily be productive of a cure. I must frankly avow that,
were I personally the subject of aneurism, I would rather take the
chances of the disease, than of the treatment.
In the first edition of this work, I proposed a new treatment for
hypertrophy of the heart, opposed to that of Albertini and Valsalva,
and their supporters, Laennec, MM. Bertin and Bouillaud, &c. I
had found that excessive blood-letting, by inducing the anaemic state,
increased palpitation, favoured the supervention of dropsy, and
hurried the case to a fatal termination. On the contrary, 1 found
that moderate bleedings at long intervals, as six or eight ounces
every three to six weeks or more, reduced the action of the heart
without diminishing the fibrinous quality of the blood. The decided
success which has attended this treatment of hypertrophy, has led
me to apply it to aneurism of the aorta; and the results have been far
more satisfactory than any that I have witnessed from the profuse
bleeding system of Albertini and Valsalva. Others seem to have
made similar observations. Thus Dr. Beatty remarks, respecting his
case reported in the fifth vol. of the Dub. Hosp. Rep., that the pa-
tient experienced relief, when he changed from a reducing system to
a more nutritious and generous diet. Dr. Stokes has made a similar
remark on another case, in the Dub. Jour. vol. v.
In conformity with these principles, the treatment, in my opinion,
should be as follows: The patient should, in the first instance, be
pretty copiously bled, from twelve to twenty ounces being drawn,
according to the age and streng'h. After this, it will generally be
sufficient to abstract gvi or viii every three to six or more weeks, the
quantity being the larger, and the interval shorter, in those who are
robust and plethoric, and speedily reproduce blood. An increase in
the strength of the pulse, and of the pulsations of the tumor, should
be the signal for the depletion. But when the first signs of anaemia
display themselves by slight paleness of the complexion and lips, a
little jerk in the pulse, a sense of palpitation of the heart, and a feeling
of general debility, bleeding should be entirely suspended till this
state has been completely removed ; for it indicates that the deple-
tion has already been carried a little too far.
Purgatives and diuretics may be made to co-operate with vene-
section. It might be imagined that purgatives alone would suffice to
reduce the mass of fluids in the system, without the aid of blood-
12— b 20 hope
446 HOPE ON DISEASES OF THE HEART.
letting. Experience, however, has convinced me that this cartnot
always be accomplished without a degree, and a continuance, of pur-
gation highly intolerable to the patient, and not exempt from the
danger of permanently injuring the mucous membranes. Occasional
purgation, however, continued for a week or ten days at a time, may
be resorted to with great advantage after blood-letting; as it keeps
down the quantity of the blood, without depriving it to the same de-
gree of its fibrine. In this view, the purgatives which produce aque-
ous evacuations are the most suitable. The neutral salts will suffice
for ordinary occasions; but when a powerful effect is required,
nothing is comparable to elaterium, by which two or three pints of
serum, or more, may sometimes be drained away in twenty-four
hours. Jalap and bitartrate of potass have in a less degree the same
effect. Diuretics may be given on the same principle. These reme-
dies, no less than bleeding, should be employed short of that degree
which would produce ansemia.
Digitalis is eminently useful in the treatment of aneurism, by en-
feebling and retarding the action of the heart and arteries, and thus
promoting the stagnation of blood within the sac. So decidedly has
it this effect, that 1 have found it a dangerous remedy in organic dis-
eases of the heart attended with great debility of the organ; since it
is apt to prove fatal by creating polypus (see Polypus).- In aneu-
rism, the patient, if suitably watched, may be kept moderately under
its influence for several consecutive weeks, when an interval of a
week or two may be interposed, to obviate any cumulative poison-
ous effect. If the heart be simultaneously affected with dilatation
and attenuation, softening, or great valvular disease, the omissions
should be at shorter intervals, and the doses should always be mo-
derate, for the reason above assigned.
The well-known effect of the acetate of lead in controlling active
hemorrhages, has introduced this as a remedy for aneurism. In Ger-
many it has been extensively used for many years, and Dupuytren,
Laennec, and Bertin have employed it with advantage in France.
My own experience is in its favour. It may be given occasionally,
where digitalis disagrees, or when the patient tires of that remedy,
or takes a prejudice against it. Its tendency to produce inflamma-
tion of the mucous membrane of the stomach and bowels may be
counteracted by conjoining it with opium, or, as Dr. Thompson has
pointed out, with vinegar. I have seldom found inconvenience from
a grain, with half a grain of opium, in a pill, given three or four times
a day. So small a dose, however, is insufficient to produce a full
effect. For thisVeason, and also because opium is a stimulant to ca-
pillary action, the formula with vinegar is perhaps preferable. Two
or three grains of the acetate, in a pill, may b.e safely given every
four hours, provided it be washed down by a draught containing half
an ounce of common vinegar, or an equivalent quantity of strong
acetic acid. Sometimes the vinegar itself irritates; but this may be
in a great measure obviated by a liberal addition of sugar, or, if this
fail, by tr. opii m iv or v with each dose. If, notwithstanding these
ANEURISM OF THE AORTA TREATMENT. 447
precautions, gastro-intestinal irritation should result from the lead, 1
have always found it easily removed by the prompt administration
of a dose or two of castor oil, with the free use of mucilaginous
diluents and a farinaceous diet for two or three days.
The diet for aneurism should be as dry as is compatible with the
patient's comfort; since much liquid tends to fill the vascular system
with aquoous blood, which it is the object of the treatment to pre-
vent. To those who have a strong disposition rapidly to reproduce
rich, fibrinous blood, animal food should be allowed only sparingly,
— for instance, not oftener than every second or third day. But in
a large proportion, this disposition does not exist: on the contrary,
under a farinaceous or vegetable diet, there is often a decided ten-
dency to an impoverished state of the blood. Here, animal food
should be allowed daily. In short, the principle of keeping the pa-
tient low, yet just short of that degree which would induce anaemia,
should be the practitioner's constant guide.
The utmost corporeal quiescence is indispensable; as acceleration
of the circulation by efforts not only defeats the object of the treat-
ment, but is even incompatible with safety, as rupture of the sac
might be the consequence. The patient ought, in fact, to be almost
constantly in the sitting or lying position. If exercise be permitted
at all, it should not exceed a quiet pace about the room, or gestation
in an easy carriage, into which the patient should submit to be lifted.
On the same principle, the utmost mental tranquillity is desirable.
External applications are not to be neglected under suitable cir-
cumstances. When there is much pain in the tumor, leeches sometimes
afford great relief; but, when the integuments are very thin and dis-
coloured, they should not be applied to the immediate part, lest they
ahould induce sloughing and rupture of the sac.
Ice, as an application to the tumor, has been strongly recommended;
but the pain which it produces is in general intolerable beyond a short
time. Its occasional use, however, and, in the intervals, a cold cata-
plasm of linseed meal and vinegar, are very serviceable by contracting
all the tissues, and promoting the coagulation of the blood within
the sac, when its current has been rendered languid by depletory
measures. When cold applications are not employed, and the tumor
is painful and requires support, I have found the emplastrum Bella-
donnas afford the greatest relief.
When the aneurism is of the false, or even of the mixed species,
as may in general be presumed when it is seated in the descending
aorta, whether thoracic or abdominal, the treatment should be steadily
pursued for one, two, or three years, with a curative object; for ex-
perience has proved that such aneurisms occasionally admit of a radi-
cal cure. I mention so long a period as three years, because a pa-
tient should not venture to return to active habits, until a year at
least has elapsed after the disappearance of all the symptoms; such a
term being requisite before the coagulum which has filled the sac can
undergo a sufficiently firm organization and induration to render the
reparation secure. When the aneurism is of the true species, which
448 HOPE ON DISEASES OF THE HEART.
is generally the case with those of the ascending aorta and arch, a cure
is scarcely to be anticipated, as coagula can scarcely ever be made to
form in the sac. Still, by a judicious management of the treatment,
a valuable life may often be greatly prolonged.
In cases of mere dilatation of the aorta or arch, as the immediate
danger is by no means so great, more latitude in exercise may be
permitted. The object here is, in the first place, to obviate the in-
crease of the dilatation, and, in the second, to prevent its inducing
enlargement of the heart by the obstacle that it presents to the circu-
lation. By the tranquil system which has been pointed out, these
two objects may frequently be attained, and the patient's life pro-
longed for an indefinite series of years.
Treatment of Jlnamiic and Nervous Pulsation of the Aorta. — If the
case be one of mere anaemia, without more nervous excitability than
that state ordinarily induces, the patient may at once be submitted to
the almost infallible remedies for aniemia; namely, iron in large doses,
continued for a month or two; aloetic aperients, sufficient to move
the body once or twice daily, without relaxation; and a large propor-
tion of slightly under-dressed animal food, at breakfast and dinner.
Wine and porter are too stimulating till the anaemic state is nearly
gone. A dry bracing air, much out-door occupation short of fatigue,
and a cheerful amused state of the mind, are most desirable auxiliaries.
The drain of leucorrhaea, if it exist, must of course be arrested, and
this object may in general be easily attained by the daily injection of
half a pint of cold water containing ^ss of liq. plumbi aeetatis. The
bleeding of piles also demands the immediate use of cold water lave-
ments, or of the other usual remedies for that affection. Menorrha-
gia should be checked by the ordinary means.
If the patient be more than commonly nervous, the above remedies
are apt to prove too stimulant in the first instance, and they should
therefore be preceded for a week or two by a broth and fish diet, ade-
quate aperients, sedatives as hyoscyamus, tr. lupuli, extr. lactucae or
conii, and, if there be hysterical symptoms, by these conjoined with
antispasmodics, assafcetida, galbanum, valerian, musk, aether, shower-
bath, &c. Iron and animal food should then be commenced in mode-
rate doses, and gradually increased.
It is in vain to attempt the latter remedies while there is any chronic
gastro-enteritis or colitis in existence, — affections which are a common
cause of anaemia, and which requite an opposite treatment.
MALFORMATIONS OF THE HEART. 449
CHAPTER XI.
MALFORMATIONS OF THE HEART.
Malformations of the heart are imperfections, generally congenital,
in the structure of the organ, and they consist in a deficiency, a super-
abundance, or an anomalous configuration of parts. The number of
varieties of malformation is considerable, and they are so irregular
in their combinations as scarcely to admit of being classified on ge-
neral principles. All worthy of notice that have hitherto been met
with, are comprised in the following catalogue.
1. The heart is single, like that of a fish, consisting of one auricle,
and one ventricle from which springs a trunk that presently divides
into the aorta and pulmonary artery. The patients have generally
died within ten days.1
2. There are two auricles, and one ventricle. In one case the pa-
tient attained the age of twenty-two.3
3. The foramen ovale remains open. This is the most common
malformation, and is found at all ages, sometimes even at the extreme
period of senility.3
4. The foramen ovale and ductus arteriosus both remain open.4
5. The foramen ovale and ductus arteriosus are open, and the
pulmonary artery obliterated at its origin. In one case, the cavity
of the right ventricle was nearly obliterated, and in two others the
septum of the ventricles was perforated.5
6. The septum of the ventricles is totally deficient, and that of
the auricles very imperfect.6
7. The aorta arises from both ventricles, i. e. The septum of the
ventricles being deficient at the mouth of the aorta, forms a common
opening between that vessel and the two ventricles. It is generally
accompanied with contraction of the pulmonary artery, frequently
with an open state of the foramen ovale, and occasionally with ob-
i Vid. a Case in the Philos. Trans, v. 88, p. 346; another, ibid. v. 95, p. 228;
another in Dr. Farre's Path. Research. Essay 1, p. 2; and two in the Ephem.
nat. cur. Dec. 1. ann. 4 and 5, Obs. 40; and Dec. 2, ann. 10, Obs. 44.
- Case by Wolf, mentioned by Kreysig, die Krankeitendes Hertzens. Berlin,
de 1814 a 1817, viii. p. 200; and one was seen by Breschet.
3 Passim. It has been found in the a^ed by Albinus. Academ. Annot. Lib.
i. cap. ix.; and Burns on Diseases of the Heart, p. 8.
4 Deschamps, Fouquier, Thibert, Monro, Burns, &c.
5 W. Hunter, Med. Obs. and Inq. v. vi. p. 291. — Farre, two cases, Path.
Research, p. 19. Two died within thirteen days: one lived six months. [Case
of Cyanosis by Dr. Rohrer, — American Medical Intelligencer, vol. iv. p. 145 —
child lived eleven months. — P.]
6 Farre, Path. Research, p. 30. Senac, Traits sur la Structure du Coeur, v.
li. p. 404.
29*
450 HOPE ON DISEASES OF THE HEART.
literation of the pulmonary artery and patescence of the ductus ar-
teriosus.1
8. The septum of the ventricles is perforated. The aperture is
small, and, though near, it is not immediately in the mouth of the
aorta. With this state, the pulmonary artery is sometimes contracted,
and the foramen ovale open.3 A similar perforation appears to be
formed by ulceration, and this, in one case, took place at the point of
junction of the septum of the auricles and ventricles, so that the four
cavities of the heart communicated.3
9. The pulmonary artery arises from both ventricles, and the fora-
men ovale is open. This vessel sends off the descending aorta, while
the ascending arises in the natural way.4
10. The aorta springs from the right ventricle, and the pulmonary
artery from the left, the foramen ovale, and sometimes also the ductus
arteriosus, remaining open.5
11. The right auricle opens into the left ventricle instead of into
the right, and the ventricles communicate by an aperture immediately
below the aortic valves. The foramen ovale is open.6
12. The arch of the aorta was double in a child of twelve or thir-
teen years old seen by Bertin the father.
13. The foramen ovale is closed in the foetus.7
14. The valves sometimes exhibit defects which have been sup-
posed to be congenital, but which are more probably referable to endo-
carditis, if the patient has ever laboured under that affection: namely,
the mitral, the tricuspid, and the pulmonic valves have been found
stretched flat across their orifices, with a perforation in the centre.8
The membranous part of the several valves has been found perfo-
rated: in one instance it resembled a net-work.9 I have seen several
such. They have been supposed to be congenital affections, but they
are mere results of atrophy, and occur in the atrophous and anae-
mic alone.
[15. Absence of the tricuspid valve, and of the ductus arteriosus — no mus-
culi pectinati in the right auricle. Pulmonary veins emptying into the right
auricle, vense cavae into the left. Deficient ventricular septum; no semilunar
valves in the aorta; aorta communicating with both ventricular cavities. Pul-
monary artery arising from the left ventricle.
1 Corvisart, p. 293-8, three cases,— ^-Sandifort, Obs. Anat. Path. cap. 1, p. 35. —
Bartholinum, Acta Hofniensia, torn. i. p. 200. — Abernethy, Surg, and Phys.
Essays. — Farre, Path. Res. p. 26. — Ed. Med. and Surg. Jour. vol. ix. p. 399.
Tredeman, Stander. The Writer, p. 458.
2 Dr. Hunter, Med. Obs. and Inq. v. vi. p. 299, two cases. — Corvisart,
p. 276.
3 Laennec, torn. ii. p. 547. — Thibert, Bouillaud.
4 Two Cases by Sir A. Cooper.
5 Farre, Path. Research, p. 29. — Langstaff, Lond. Med. Rev. p. 88. — Baillie,
Morbid Anat.
6 A case by Holmes, Ed. Med. Chirurg. Trans, p. 252. The right auricle
equalled a pint in capacity. The patient attained the age of twenty-one.
7 Vieussens sur la Structure du Caeur, c. viii. p. 35.
8 Burns, Morgagni, Laennec, Louis, Bertin.
9 Laennec, ii. p. 550,
MALFORMATIONS OF THE HEART. 451
The above lesions (15) were presented upon the post-mortem examination
of a child who had been a patient under the charge of Dr. Worthington, of
West Chester, Pa., and are so remarkable in character, that I think it proper
to introduce his account of the case: —
"The subject of the following remarks, was a female child, who had been
liable from birth to almost daily attacks of oppressed breathing, attended with
blueness of the skin and nails. It was evident from the symptoms, that the
venous and arterial blood mingled in such a way, as to be thrown over the sys-
tem in a mixed state. No doubt was entertained that malformation of the
heart existed, and it was confidently believed, that the foramen ovale remained
open. Some time previous to its death, which occurred when about 22 months
old, it began to emaciate; had occasional cough and diarrhoea. Its blueness,
and other symptoms, continued during the whole period of its life; and such
was the distress and embarrassment which accompanied the respiratory and
circulatory functions, that it was necessary to keep the child almost constantly
under the influence of anodynes. Digitalis was also administered with a view
to retard the action of the heart. The peculiar symptoms were most likely to
recur, whenever the child was agitated, or became fretful.
" Post- Mortem. — When making the post-mortem examination, the following
peculiarities were noticed. The heart was divided into the four usual cavities —
two ventricles and two auricles. The right auricle was very small, and exhibited
no appearance of musculi pectinati. The pulmonary veins emptied into this ca-
vity, and the auricle seemed to be merely a dilatation of these vessels. There
was no opening between this part of the heart and the right ventricle. The fora-
men ovale remained open, so that the blood from the lungs passed directly through
this opening into the left auricle. The venae cava? emptied their contents into the
left auricle. This cavity was larger than natural, and presented the usual ap-
pearance of musculi pectinati commonly found in the right auricle. These two
cavities, both in structure and office, seemed to be merely transposed. The os-
tium venosum existed in the left side of the heart, with its usual valves. The
ventricles were of the ordinary size and thickness. Their interior structure pre-
sented the usual appearance. The aorta arose from the right and left ventricles
by a spreading mouth, which formed a communication with both those cavities.
The septum between the two ventricles immediately under the mouth of the
aorta was defective in such a way, as to form an opening between them. The
pulmonary artery arose from the left ventricle a short distance from the aorta.
No ductus arteriosus existed. This passage in the foetal state being unne-
cessary, on account of the aorta and pulmonary artery proceeding from the
same cavity. The usual valves at the mouth of the aorta were wanting; which
circumstance, no doubt, contributed very materially to increase the embarrassed
state of the circulation.
" From the peculiar formation of the heart, it is very evident, that the circula-
tion must have been conducted in the following manner. The blood as it re-
turned from the general system was received by the vena? cava? and carried into
the left auricle; where it met the blood returning from the lungs through the
pulmonary veins, right auricle, and foramen ovale. The arterial and venous
blood here mingled, and, in this state, passed directly into the left ventricle
through the ostium venosum. By means of the opening in the septum between
the ventricles, at the mouth of the aorta, the blood had access to the right ven-
tricle; and from the two ventricles it was thrown into the aorta, and at the
same time into the pulmonary artery, and returned again through the proper
vessels to meet in the left auricle. "i — P.]
Professor Dunglison in the American Medical Intelligencer for 1840-41, p.
147, has communicated the following interesting remarks on the disease in
question: —
" The pathological appearances found on the dissection of those who have died
of cyanosis or kyanosis, are diversified and curious. All permit the admixture
1 American Journal of the Medical Sciences, vol, 22. p 131.
452 HOPE ON DISEASES OF THE HEART.
of venous with arterial blood, so as to give rise to the peculiar blue colour of
the surface.
" Gintrac,1 who was professor of anatomy and physiology at Bordeaux, has
collected the appearances presented on the dissection of fifty-three cases. In
twenty-two of these, the aorta was found to arise from both ventricles. In
thirty-three, the foramen ovale was open; in fourteen, the ductus arteriosus
was wanting; in four, the heart was single, consisting of one auricle and one
ventricle; in five, the ventricular septum was imperfect; in twenty-two, the pul-
monary artery was contracted; in five, that vessel was obliterated; in one, the
aorta was obliterated; and in four, the aorta arose from the right ventricle,
the pulmonary artery from the left.
The various malformations of the heart have been well investigated by dif-
ferent pathological writers, and especially by Meckel,2 and Hope, and more
recently still by Warnatz3 of Dresden — the last writer having described them
in reference especially to kyanosis.
" The heart," when presenting the appearances mentioned under the fifth
division of Hope, " appears to resemble that of the higher reptiles, (hoheres
Reptilienherz, of Meckel,) the ophidian, saurian, and chelonian, which con-
sists of two auricles with a partitioned ventricle or a single ventricle. Meckel4
refers to many such cases described by Pulteney, Hunter, Sandifort, Nevin,
Abernethy, Cruikshank, Prochaska, Caillot and Duret, Corvisart, &c, and
Warnatz,5 to others by Kreyssig, Hartmann, Tiedemann, Gintrac, Senac, Wolf,
Lexis, Spittal, Bird, Beckhaus, Hunter, and others; but although these cases
greatly resembled each other in the fact of a ready communication existing be-
tween the ventricles, they differed greatly in the details.
" In Lexis's case,6 the aorta arose from the ordinary place in the left ventricle,
which was more than usually developed; at the same time, there was an
opening through the septum ventriculorum in a straight line with the embou-
chure of the aorta, which permitted a free communication between the right
and left ventricle, in such sort that one half the aorta might be considered to
open into the right and the other into the left ventricle. The pulmonary
artery was greatly diminished in size.
" In a case related by Bird,7 besides hypertrophy of the heart, a ready commu-
nication existed between the right ventricle and the aorta, at the place where the
pulmonary artery ought to have been, and at the same time the carotid arose
from the left ventricle.
"In another case, related by Beckhaus,8 of a 'blue ' child, but a slight trace
existed of the septum ventriculorum; the valve of the foramen ovale, which was
open, and the eustachian valve were present; and the ductus arteriosus was di-
vided into two branches, one of which went to the right and the other to the
left lung from the aorta; the pulmonary artery was wholly wanting.
" Generally, the pulmonary artery has been found of very small size. (Aber-
nethy, Sandifort, Stenson, Hunter, Nevin, Caillot and Duret, Hope.) Duret
and Caillot9 not only found the mouth of the pulmonary artery very narrow, and
the coats thinner than usual, but the artery itself entirely impervious, and the
ductus arteriosus wholly obliterated. Ramsbotham10 found the pulmonary ar-
1 Observations et Recherches sur la Cyanose, ou Maladie Bleue. Paris, 1824.
2 Handbuch der Pathologischen Anatomie, von Johann Friedr. Meckel, u. s. w.
Band 1,S. 419. Leipz. 1812.
3 Art. Kyanosis, in Encyclopad. Worterb. der Medicin. Wissensch. Band xx. S.
608. Berlin, 1839.
4 Op. cit. S. 427.
5 Loc. citat. S. CIO.
6 Hufeland's Journal fur. 1835, St. 12.
7 Horn's Archiv. fur 1821. Hft. 1.
8 De Deformationibus Cordis Congenitis, &c. Berol. 1825, cited by Warnatz.
9 Meckel, and Warnatz, Op. citat.
10 London Medical and Physical Journal} Jan. 1829.
MALFORMATIONS OF THE HEART. 453
tery entirely wanting, its place appearing to have been supplied by the bron-
chial arteries.1 Romberg^ in a case of cyanosis, found the aorta near the heart
terminate in a cul-de-sac. It had received its blood through the ductus arte-
riosus from the pulmonary artery, which was of unusual size. The child lived
four days.
" It would appear, therefore, from all the pathological investigations which
have been instituted, that the main causes of cyanosis, or of the admixture of
venous with arterial blood, &re, first, the want of closure of the foramen ovale;
secondly, the patescence of the ductus arteriosus beyond the proper period.
Thirdly, the patescence of both the foramen and the duct beyond the normal
time. Fourthly, an abnormous opening or openings in the septum between the
ventricles, whicli have thus a free communication with each other and with the
aorta; and, along with this malformation, narrowness or obliteration of the pul-
monary artery. Fifthly, defective formation of the heart, which consists of
but one auricle and one ventricle; and lastly, abnormous origin of the vessels
from the heart."3— P.]
Of all the causes of communication between the two sides of the
heart, patescence of the foramen ovale is the most frequent. This
either results from the two layers of which the valve consists in the
foetus, not becoming adherent, — a common form of patescence, and
one which does not appear to occasion any material inconvenience:
or the foramen is dilated and permanently open, being sometimes
large enough to admit the thumb. This dilated state is generally
congenital; Louis thinks it is almost always so: but, as many patients
have dated their symptoms of disease of the heart from a fall, blow,
or violent effort, it is probable that, in such cases, these accidents
had caused either the rupture of the membrane closing the foramen,
or the separation of its imperfectly agglutinated layers; whence en-
sued the progressive enlargement of the aperture. Bouillaud gives
two cases of communication from ulceration through the partitions.
Whatever be the mode of communication between the two sides
of the heart, its effect is, with few exceptions, to cause an intermixture
of the arterial and venous blood. One exception, and the most com-
mon, is, when the two layers of the foramen ovale are simply non-
adherent; for they are then closed like an oblique valve by the pres-
sure of the blood on each side, a pressure which exists as well during
the diastole, as the systole of the auricles; for, according to the ex-
periments of the writer, the auricles are constantly full, though
sometimes more distended than at others. A second exception may
possibly exist when the pressure of blood on each side of a gaping
aperture is equal. But such cases are, I believe, more imaginary
than real; for it scarcely ever happens that there is not, on one side or
the other, some valvular or analogous obstruction, which, by impeding
the current of the blood along its natural channel, renders its pressure
through the morbid aperture stronger than that in the opposite direc-
tion. Thus, in more than half the cases of communication between
the right and left cavities of the heart, there is a contraction of the
1 See, also, Muller, in Horn's Archiv. fur 1822, Hft. 3. Hunter, Medical Commen-
taries by Duncan, ix. 323.
2 Dissert, de Corde Vasisque Majoribus, &c. Berol. 1824.
3 Warnatz, Op. citat. S. 616,
454 HOPE ON DISEASES OF THE HEART.
pulmonary orifice, or of the pulmonary artery itself, and this, by
gorging the right auricle, causes a predominant pressure of blood
into the left, when the foramen ovale is open: when it is not, the pul-
monic contraction, assisted, as is mostly the case by hypertrophy
of the right ventricle, might even occasion a predominant pressure
of blood into the left ventricle through an aperture in the septum.
When there is no contraction of the right orifices, the superior strength
of the left ventricle would cause the passage of blood out of this
cavity, or even out of the aorta (case of Mitchell), through a morbid
aperture, into the right ventricle: and a contraction of the aorta or
left orifices would occasion a predominant pressure out of the left
auricle into the right, supposing the foramen ovale to be open.
The communication of the two sides of the heart is almost con-
stantly accompanied with hypertrophy or dilatation of the right cavi-
ties, whereas the left are very rarely affected. This remark has been
corroborated by the subsequent cases of Louis and of Bouillaud.
Thus, of twenty cases by Louis, dilatation, six times with hyper-
trophy, and twice with attenuation, affected the right auricle in nine-
teen. Dilatation affected the right ventricle in ten; hypertrophy in
eleven; hypertrophy with dilatation in five. Whereas, on the left
side of the heart, dilatation of the auricle was observed in three only,
that of the ventricle in four; its hypertrophy in three; and hyper-
trophy of the auricle in two, — precisely the inverse of what is ordi-
narily seen.
Of eleven cases in which the size of the heart was noticed by Bouil-
laud, dilatation of the right auricle existed in ten, — five times with
hypertrophy: hypertrophy of the right ventricle existed in ten, four
times with contraction. The left cavities presented nothing parti-
cular, except in three cases, in which there was valvular contraction
of the left orifices (Traite, ii. p. 567).
MM. Bertin and Bouillaud attribute the hypertrophy to the in-
troduction of a certain quantity of red, arterialized blood into the
right cavities, which they think calculated to occasion their hyper-
trophy in consequence of its being more irritating, more nutritive,
possessed of more vitality, than the venous blood.
I doubt whether this ingenious hypothesis is tenable, as the most
remarkable cases of hypertrophy of the right ventricle have been
those in which there was extreme contraction of the pulmonary ori-
fice, when, consequently, the current through the foramen ovale must
have been so decidedly from the right to the left side, that no arte-
rial blood could possibly have entered the right ventricle.
What, then, was the cause of the hypertrophy of that ventricle?
The contraction, I should imagine, of its pulmonary orifice; in the
same way that contraction of the aortic orifice occasions hypertrophy
of the left ventricle. MM. Bertin and Bouillaud support their opi-
nion by the circumstance that the hypertrophy is often accompanied
with contraction of the cavity, which, they think, would not be the
ease if the hypertrophy resulted merely from too great a quantity or
too great a distending pressure of the blood. To this it may be re-
MALFORMATIONS GENERAL SIGNS. 455
plied that, in the left ventricle, hypertrophy with contraction arises
more frequently from a similar cause, that is to say, obstruction of
the aortic orifice, than from any other; the reason of which I have
attempted to explain in the article on hypertrophy, p. 252. It might
be objected to this, that, in many cases though the pulmonary artery
was obstructed, the ventricle discharged itself by an opening into the
left ventricle or into the aorta. True; but this discharge was not
made with the same facility as in the natural way through the pul-
monary artery, inasmuch as the weight of the aortic circulation ex-
ceeds that of the pulmonary.
Having said so much to account for the hypertrophy, we have next
to consider the cause of the dilatation which is occasionally found in
the right cavities. This is manifestly an effect of over-distention; for
as far as I can discover, it is always accompanied with an excess of
blood gorging the right cavities, in consequence of a mechanical ob-
stacle, or impediment in front of the cavity dilated. Thus, in a case
by Corvisart (p. 276), the excessive smallness of the aorta caused
the blood to flow out of the left auricle into the right, through the
foramen ovale, which was more than an inch in diameter, and thus
to produce dilatation with hypertrophy of the right cavities. So,
again, the right ventricle is apt to become dilated when the weight
of the aortic circulation is thrown upon it by a communication be-
tween the two ventricles.
While I thus contend that there are sufficient mechanical causes to
account for hypertrophy and dilatation of the right cavities in cases
of communication between the two sides, 1 do not wish to assert
that the introduction of arterial blood may not contribute to the pro-
duction of hypertrophy. On the contrary, I think it probable
that it does, since the arterial blood is a morbid stimulus of the right
cavities; but it is repugnant to the principles of inductive science
to assign this, which is at best problematical, as the sole cause, over-
looking others, the effect of which is unquestionable. M. Bouillaud,
in his recent work, has adopted the same view (ii. p. 575).
General signs of communication between the two sides of the Heart. —
The signs given by authors, are, a violet or blue colour of the skin,
in general much more intense and extensive than in any other ma-
lady, and sometimes even universal; a reduction of temperature, with
great sensibility to cold; unusually frequent attacks of syncope; oc-
casionally, convulsions; and a greater difficulty of the respiration
than in most other diseases of the heart.
These symptoms are sufficiently correct in reference to the cases in
which there is distinctly a violet or blue tint, with its almost inse-
parable concomitant, an obstructed circulation; but there are nume-
rous cases of communication, in which the intermixture of venous
and arterial blood, and the obstruction of the circulation, are so in-
considerable, that the blue tint is absent, and the general signs are
only those of a moderate valvular obstruction. Here, the physical
pigns and the history are the only means by which we can arrive at
the diagnosis, and it will be convenient to consider them conjointly
456 HOPE ON DISEASES OF THE HEART.
under the head of physical signs, to which we shall presently come.
Meanwhile it is necessary to revert to the blue discoloration of the
skin, (designated by the names blue disease, blue jaundice, cyanosis,)
as its causes and circumstances do not appear to me to have been
fully understood and explained by authors. When the intermixture
of the arterial and venous blood is not very considerable, and espe-
cially when the admission of venous blood into the lungs is free, the dis-
coloration is sometimes not deeper than is to be found in cases of or-
dinary obstruction to the return of the venous blood, and occasionally
it scarcely exists at all. On the contrary, when the ingress of venous
blood into the lungs is very limited, and the intermixture with the
arterial considerable, the colour is of the deepest dye, and pervades
not only the lips, nose, ears, and face, but the hands, the feet, and, in
greater or less intensity, the skin universally. Such, at least, is the
generalization to which I have been brought by the cases that I have
seen, and by an examination of nearly all that have been published
on this subject. M. Jul. Cloquet and M. Bouillaud say that when
red blood passes from the left into the right cavities, it cannot occasion
cyanosis (Traite de Bouillaud, ii. p. 575 and 573;) but this is a mistake;
for if arterial blood replace venous in the right cavities, a diminished
quantity of venous blood is transmitted to the lungs for arterialization;
whence the total mass in the system is darkened. This occurred, for
instance, in the case of Mitchell, whose tint was unusually dark.
According to M. Laennec, the blue colour of the skin is equally
marked and extensive in some diseases of the lungs, particularly em-
physema, as in cases of communication between the two sides of the
heart. This is not consistent with my own observation; for, of many
thousand cases of pulmonary disease which I have seen, in not one,
nor in any ordinary organic disease of the heart, has the colour ad-
mitted of comparison with that which I have witnessed, and of which
I shall presently offer an instance, in cases of the communication in
question.
For this reason I must dissent from the opinion of MM. Bertin
and Bouillaud, and of M. Bouillaud in his later work, who maintain
that the blue or violet colour depends, not on intermixture of the
black with the florid blood, but " principally, if not exclusively," on
the same cause that occasions it in cases of ordinary obstruction to
the circulation: namely, " the stagnation of the blood in the right
cavities of the heart, and in the venous system, which is as it were
gorged with it." MM. Louis and Ferrus entertain the same opinion.
Were this true, cases of intense discoloration would be of ordinary
occurrence, instead of being extremely rare, and presenting them-
selves in those almost exclusively, who are affected with a commu-
nication between the two sides of the heart.
Venous retardation, however, co-operates with the intermixture
of blood in darkening the colour, and it is also the main cause of
dropsy, passive hemorrhages, &c.
It is scarcely necessary to remark, that when hypertrophy or dila-
tation co-exists with malformation, the effects and signs resulting
from them are added to those of the congenital disease.
MALFORMATIONS — PHYSICAL SIGNS. 457
Physical Signs. — Laennec had not an opportunity of studying
cases of malformation with the stethoscope. In a case subjoined
(Collins), of which I made a post-mortem examination, the signs
were conformable to the general principles developed in the several
articles on organic diseases of the heart: namely, enlargement of the
organ by one-half was indicated by dulness of the precordial region
on percussion and slight prominence; hypertrophy of the right ven-
tricle was denoted by increased impulse at the inferior part of the
sternum; contraction of the pulmonary orifice, and a common open-
ing of the right ventricle with the left into the aorla, occasioned a
loud, superficial hissing murmur with the first sound, loudest about
the middle of the sternum, over the orifices affected.
In another case subjoined, of a living patient (Master R.), the signs
were almost identical. In a third, a young lady, aet. 12, with cyanosis,
there was an exceedingly loud and superficial murmur over the pul-
monary artery, from its valves to the top of the sternum. I have
met with a few other cases presenting more or less similar signs, but
have not had the opportunity of post-mortem verification, except in
the single case of Collins. The cases of other authors afford little or
no information respecting the physical signs, as murmurs are very
rarely mentioned, and when they are, it Is only in general terms.
Thus, out of fifteen cases, collected from various sources by Bouillaud,
in one only is it stated that there was a bruit de soufflet in the pre-
cordial region. Drawing, therefore, from my own limited observations
until a greater number of cases have been carefully collected, and
guided by the general principles which are offered in this work as
applicable to particular valvular diagnosis, I should think that the
murmurs indicative of a communication between the two sides of
the heart would be nearly as follows: —
An unusually loud and superficial or near-soiaicling murmur with
the first sound, immediately over the semilunar valves, (that is, about
opposite to the inferior margin of the third rib), is generally seated
in the mouth of the right ventricle, and may proceed either from a
contraction of the pulmonic valves or orifice, or from an opening out
of the right into the left ventricle, or from both these lesions corn
joined. If it proceed from contraction of the pulmonic valves or
orifice alone, it will be audible along the course of the pulmonary
artery, up to the second intercostal space, much more distinctly than
along the course of the aorta, and will be attended with a thrill. If
it proceed solely from an opening out of the mouth of the right into
the left ventricle, (the pulmonic orifice being either healthy or totally
obliterated,) it will be more audible along the course of the aorta
than along that of the pulmonary artery. If it proceed from the
double lesion, namely, a contracted pulmonic orifice and an opening
into the left ventricle, it will be loudly audible along the course of
both vessels, and a thrill will be felt over the pulmonary artery.
When these signs of a lesion in the mouth of the right ventricle coin-
cide with cyanosis, the evidence of a communication between the
two sides of the heart is almost positive, and, as hypertrophy of the
12— c 30 hope
458 HOPE ON DISEASES OF THE HEART.
right ventricle is usually a concomitant, its presence is a corrobora-
tive-circumstance. When the signs in question do not coincide with
cyanosis, an appeal must be made to the history of the case. If it
appear that the patient has exhibited the symptoms of organic disease
of the heart from early infancy, yet has never been affected with en-
docarditis to which the valvular disease could be ascribed, there are
strong probabilities of a congenital malformation, and presumptions of
a communication between the two sides, — though without so consi-
derable an intermixture of blood, or so great an obstacle to its ingress
into the lungs, as suffices to occasion cyanosis.
A farther appeal may be made to numerical considerations. The
frequency of contraction of the right orifices, especially the pulmo-
nic, in cases of communication of the two sides of the heart, is very
striking. Of 50 cases of cyanosis collected by M. Gintrac, 27 pre-
sented obstruction of orifices, and its seat in 26 of them was in the
pulmonic orifice, and in 1 in the tricuspid. Of 15'cases collected by
Bouillaud, 12 presented valvular disease; in 10 of which there was
contraction of the orifice. In 8 out of the 12, the lesion was in the
right valves; and in 5 out of these 8, the pulmonic valves wrere its
seat, in 1 the pulmonic and tricuspid together, and in 2 the tricuspid
alone. Thus, in cyanosis, the numerical chances, according to the
above cases, are 32 to 3, or more than 10 to 1, that there will be con-
traction of the pulmonic orifice: and conversely, as contraction of
this orifice from ordinary causes is extremely rare, its presence.,
when not distinctly traceable to inflammation, affords very strong nu-
merical presumptions that there is a communication between the two
sides of the heart, even though cyanosis be absent.
Against one source of fallacy, the auscultator must be on his guard :
namely, that of mistaking a dilatation of the pulmonary artery for a
lesion in the mouth of the right ventricle. In the latter case, the
murmur will be loudest immediately over the valves: in the former,
it will be loudest at the second intercostal space, where a strong thrill
and pulsation will also be perceptible. (See cases of Weatherly and
L. P.)
Cases. — The two following cases present excellent exemplifications
of cyanosis. The history of the latter was drawn up, at my request,
by the father, a gentleman of great intelligence and observation. It
is valuable as displaying the habitudes of a patient affected with this
disease in a much more graphic manner than can be done by a mere
enumeration of symptoms.
Mary Collins, set. 8, applied to me October 22d, 1830. Lips, nose,
cheeks, palpebral, hands and feet, of a violet colour: tongue and mouth
still darker. On a frosty day, after walking or ascending stairs, the
hue of the parts enumerated, as witnessed by myself and several
medical friends, is equal to the deep stain communicated to the skin
by black currants or the small black cherry, and the face and hands
universally are as dark as those of a mulatto. Children in the
streets often inquire in winter, "where she got blackberries at that
season." Dyspnoea on the slightest exertion, particularly ascend-
MALFORMATIONS — CASES. 459
ing; cough when hurried, not otherwise: sternum very prominent;
great sensibility to cold — constantly steals to the fire, even in sum-
mer; headache, vertigo, drowsiness, and sluggishness. Pulse very
small and weak, and when hurried, it is irregular, intermittent and
unequal.
Auscultation. — Resonance of the precordial region dull. Impulse,
considerably stronger and more extensive than natural — strongest
over the right ventricle. Sounds. — The first, a very loud, hissing,
superficial bellows-murmur; the second natural or nearly so. In six
months she died of a chronic abscess in the brain.
Diagnosis- — Patescence of the foramen ovale; hypertrophy of the right
ventricle; obstruction of the orifice of the pulmonary artery. (Slated be-
fore the dissection, at which Dr. Marshal Hall, Mr. Else, surgeon,
and others were present.)
Sectio. — The heart was one-half larger than natural: the walls of
the right ventricle were thickened to half an inch: the cavity was
slightly dilated and its pulmonary orifice contracted to the size of a
goose-quiil, while a common opening from the right ventricle, ad-
mitting the index finger, existed into the aorta and the left ventricle.
The left ventricle was one-third of an inch thick, and its cavity about
natural. The two layers of the foramen ovale were disunited, and
the handle of a large scalpel easily passed obliquely through them.
The lungs were rather flaccid, imperfectly crepitant, and universally
gorged with black blood.
In this case it was the superficial nature of the murmur which led
me to conceive that it was occasioned by an obstacle to the passage
of blood from the right, rather than from the left ventricle.
Mister R. set. 11. Consulted me in 1S30. While he is tranquil
and warm, the complexion is about two shades darker than natural,
and its tint is a purplish crimson: on the lips the colour is deeper,
and within the mouth it is a blackish violet. On ascending a flight
of stairs, the colours become intense. The hands and feet are of the
same hue, and the last phalanges of the fingers and toes are bulbous,
being one-third larger in circumference than the phalanges above.
Pulsation of the carotids: engorgement, without pulsation, of all the
veins of the neck. Left margin of the sternum prominent opposite
to the fifth, sixth, and seventh ribs. Resonance deficient over the
whole precordial region. Impulse much increased, strongest where
the sternum is prominent. Sounds. — The first is a loud, prolonged,
bellows-murmur, loudest opposite to the arterial orifices of the heart:
the second is short and loud, with a very slight filing murmur.
The following history is given by the father. " He was always
as blue as at present, and I think more so when very young. Until
the age of nine months, he was very subject to spasms of the bowels,
and also, as I used to think, of the chest. They were in general re-
lieved by immersion of the lower extremities in warm water, (which
was always kept so as to be ready within two minutes,) and by a
dose of castor oil in anise water. His respiration was always quick,
and he was always subject to cough, particularly on taking cold, to
460 HOPE ON DISEASES OF THE HEART.
which he is very liable. He perspires very freely, and, about the hands
and feet, to a great degree. When the weather is sharp and nipping,
he becomes exceedingly blue. He is very chilly, and sensible to
cold. When exposed to a cold or damp and cold atmosphere, he be-
comes as it were asthmatic; his corporeal powers are overcome with
numbness, he loses, in a great measure, the faculty of motion, and I
am sure that, if placed, on a cold day, particularly with an east wind,
in an exposed situation two miles from home, and left to return that
distance by his own exertions, his powers would become so dead-
ened that he would perish in the attempt. I have sometimes, under
such circumstances, been obliged to bring him home in a coach, or
even in my arms. He suffers less in severe frosty weather, than when
the wind blows cold and harsh, though the temperature be six or
eight degrees above the freezing point. However much inconveni-
enced by exposure to cold, he regains all his powers by the time
that he has remained half an hour in a warm room. In mild weather
he is less blue, and his respiration less oppressed. If he cuts or
scratches himself, he bleeds more than others. The finger and toe-
nails are scarcely thicker than paper, and they grow very fast, re-
quiring to be cut every four or five days. He is very subject to cy-
nanche tonsillaris, with great swelling of the parts. He suffers more
than other children from illness produced by slight or common
causes, and his health consequently suffers frequent interruptions.
I must remark, in particular, that when he becomes ill, it is not gra-
dually, by the progressive development of the symptoms, but sud-
denly, scarcely ever giving the slightest premonitory signs. Not
half an hour before a severe attack, he has often appeared in good
health. He grows remarkably fast. His temper is very quick and
irritable, but his disposition is candid, frank and generous: his mind
is active and ardent. Tongue never quite clean, and the papillae are
very large: appetite and digestion generally good: bowels free: urine
almost always turbid."
I have lost sight of the patient since the above was written, eight
years ago.
PART IV.
NERVOUS AFFECTIONS OF THE HEART.
The nerves of the heart, as of every other organ, may be affected
in two ways. They may labour under over-excitement, dependent
either on increased irritability or on excessive stimulation; and they
may be in a state of deficient excitement, dependent either on di-
minished irritability or on inadequate stimulation. These states,
when existing in a moderate degree, cannot strictly be considered
morbid. Thus, palpitation from exercise or from an exhilarating
mental emotion, and languor of the heart's action from a depressing
passion, do not rank as diseases. But when the states in question
exist in excess, and when they result, less from remote sympathies,
than from a primitive affection of the nerves of the heart itself,
they constitute diseases. Of these, the state of over-excitement com-
prises Neuralgia of the heart, or Angina pectoris and Palpitation;
while the state of deficient excitement presents Syncope. These dis-
eases will be considered in successive chapters.
Spasm of the heart, a disease imagined by Laennec alone, I believe
to be really imaginary; for I have shown that the murmurs of the
heart and arteries, independent of organic disease, which he adduced
as its sole proofs, are dependent on other well-defined causes (See p.
IIS). Convulsions of the heart, if not also imaginary, do not admit
of proof. Paralysis may result from tobacco and some corrosive and
irritant poisons; but it is foreign to the subject of this work.
CHAPTER I.
NEURALGIA OF THE HEART, OR ANGINA PECTORIS.
Neuralgia of the heart occurs in paroxysms of greater or less se-
verity, and at longer or shorter intervals. When presenting the
train of symptoms which have been denominated by Dr. Heberden
angina pectoris, it commences by a sensation of pain and constriction
in the praecordial region, accompanied with a more or less painful
numbness in the left arm, more rarely in both arms, still more rarely
in the right arm alone, and occasionally in all four extremities, of
which I have seen several instances.
At first the pain may not reach beyond the insertion of the deltoid
muscle, but it soon extends down the inside of the arm to the elbow,
30*
462 HOPE ON DISEASES OF THE HEART.
and sometimes accompanies the ulnar nerve to the extremities of the
fingers. It is not unusual for pain to exist at the same time in the
left anterior part of the chest, following the tract of the anterior
thoracic nerves. In females, it is often attended with extensive cu-
taneous neuralgia, rendering the mammae so sensitive, that the slight-
est pressure becomes painful. When the attack is smart or what is
called acute, the pain in the heart is excruciating, appearing to the
patient as if " iron nails or the claw of an animal tore asunder the
anterior part of his chest" (Laennec). With this, there is great pul-
monary oppression, amounting, in the worst cases, to suffocative
orthopnoea; the heart either palpitates violently, or it falters, nutters
and intermits:1 congestion of blood in the head, syncope and convul-
sions sometimes ensue.
The attack is commonly induced by some over-excitement of the
heart, especially that of walking up hill, to the effect of which a re-
cently loaded stomach and a wind in front, powerfully contribute, —
the latter appearing to act by stimulating the excito-motory nerves
of the face. The patient is compelled instantly to stop, and, if the
complaint be recent, the attack sometimes subsides in the course of
a few minutes by mere rest, and seldom continues longer than from
half an hour to an hour, even in cases so severe as to prove fatal.
The disease is apt to become chronic; — when it recurs more fre-
quently, is excited by slighter causes, and is sometimes so obstinate
as to resist every remedy for several hours, and even for as many
days. In these cases it is seldom that there are not some of the
physical as well as general signs denoting organic disease of the
heart, and that the latter is not found on post-mortem examination.
[When the disease has continued for some time, the paroxysms of angina, as
has been remarked, become much more easily excited: any high .mental emo-
tion, chagrin, intense thought, the act of eating, or the swallowing of fluids, or
even turning the body hastily in bed, may bring it on. Sometimes, indeed, it
may come on without any assignable cause, whilst the patient is tranquil in
bed, especially at the moment of awaking from the first sleep; " in which re-
spect it coincides," as Heberden remarks, " with many other spasmodic ner-
vous diseases." In a case which I now have under my observation, swallowing
of even small portions of food brings on a paroxysm; a similar effect takes place
upon drinking hydrant water of the usual temperature; but ice has the effect of
mitigating the pain. In this case, the whole of the abdominal parietes to the
left of the median line of body is preternaturally sensitive, whilst pressure upon
the right does not induce pain, either in the epigastric, or other regions of the
abdomen. The tongue presents a natural appearance, but the thirst is extreme.
The paroxysms of angina which first occurred about eighteen months ago, after
scenes of deep domestic distress, took place in the commencement at irregular
intervals; they then subsided for a year, and have again recurred, conjoined
with endocarditis. The patient, a lady of sixty years of age, has had occa-
sional slight attacks of articular rheumatism. During the continuance of the
paroxysms of angina she suffers greatly from the agonizing pain at the heart; —
1 1 suspect that some authors, who have described the pulse as calm, have
mistaken these characters for calmness. I have never seen the action of the
heart undisturbed in a severe case, nor do I think it possible; but it is often so
in slight cases.
ANGIXA PECTORIS CAUSES. 463
the cutaneous surface of the left side of the face, neck, left chest, especially be-
neath the left mamilla, the left half of the abdomen, are all acutely sensitive,
and the pain becomes agonizing by pressure along the left margin of the spine.
Shooting pain extends down the course of the ulna nerve of the left arm to the
ends of the fingers, and down the left sciatic nerve to the calf of the left leg;
whilst on the right side of the body, the pain is restricted to the deltoid muscle,
and to the adductor muscles of the thigh. Although the sense of oppression is
very great, it is unlike that of asthma, and the patient can at pleasure expand
the chest by a full inspiration; the respiration is calm, equal, and upon the right
side, which is free from pain, is performed naturally. The face during the pa-
roxysm is slightly flushed; intelligence natural; the pulse regular, 90 per minute,
of moderate volume, somewhat corded: the urine clear, pale and copious. The
paroxysms, which, at first were of but short duration, now extend to several
hours.
Heart, physical signs. Impulse strong, with an up-heaving movement of
the chest. Both sounds heard over the apex, where no regurgitant murmur
exists; over the aortic valves, the first sound is very rough and rasping, and
the second sound is similar to that of a bellows; same character of sounds in
the ascending aorta. The sounds are nearly normal over the pulmonary artery,
and over the right side of the heart. Percussion is flat in the precordial region
in a great extent. Most relief has been obtained by cups applied over the roots
of the left spinal nerves, and by counter-irritation by blisters, sinapisms, croton-
oil, &<c., over the same surfaces; whilst internally, camphor, and the antispas-
modics have been administered. — P.]
Causes of Angina Pectoris. — Great diversity of opinion has ex-
isted respecting the cause of angina pectoris. Different physicians
have found it connected with different organic lesions or states, and
each has supposed it to be occasioned by that, with which he has
most frequently found it co-exist. Dr. Parry, and after him Burns
and Kreysig, ascribe it to ossification of the coronary arteries; Dr.
Hooper, to affections of the pericardium; Dr. Hosack, to plethora;
Dr. Darwin, to asthmatic cramp of the diaphragm; Drs. Butler, Mac-
queen, Chapman and many others, have regarded it as a particular
species of gout; Dr. Latham lias found it connected with enlarge-
ments of the abdominal viscera, while the thoracic viscera were sound ;
and Heberden, having found it both connected and unconnected with
organic disease, thinks that its cause has not been traced out, but
that it does not seem to originate necessarily in any structural derange-
ment of the organ affected.
They who have ascribed angina pectoris to any particular cause
to the exclusion of others, have unquestionably taken too limited a
view of the subject; as experience has fully proved that it may ori-
ginate in various causes. According to my own observation, it may
originate in any cause, whether organic or functional, capable of irri-
tating the heart, or of rendering it morbidly susceptible of irritation,
and as structural disease of the organ has this effect more than other
cause, it is that on which the malady, in its severer forms, is most
frequently dependent.
The most violent cases of angina that have occurred to mvself, and,
if I mistake not, that have been recorded in books, have been con-
nected with osseous, cartilaginous, steatomatous or other degenerations
of the heart or great vessels, by which some portion of them, espe-
cially the coronary arteries, the valves and the commencement of the
aorta, was more or less deprived of its elasticity. Hence it may be
464 HOPE ON DISEASES OF THE HEART.
perhaps reasonably conjectured that, when the action of the organ is
excited, as by ascending a hill, a loaded stomach, &c. the over-ten-
sion of the rigid portion is the source of the irritation and pain. It
is no objection to this view that, at the time when the pain is the
most intense, the action of the heart is sometimes diminished — that
it feebly flutters and falters, and thaf the pulse has the same charac-
ters; for, so long as these phenomena display themselves, the heart is
in a state of engorgement — of even greater distention, perhaps, than
when it is acting violently. The proofs that such is the case are
manifest in the suffocative orthopncea, the tumid, livid state of the
face, and the diminution of the sounds of the heart.
I have also several times seen angina of considerable, but not
equal severity, accompany hypertrophy and dilatation with or with-
out softening; but I have never known the malady to exist in an ag-
gravated form — one which truly merited the name of angina rather
than of mere neuralgia, independent of some organic disease of the
heart or its immediate appendages. Cases, it is true, are on record
which appear to militate against this opinion; but as it is only of
late years that the anatomical characters of hypertrophy, of dilata-
tion, and of softening have been clearly understood, the evidence of
such cases must be admitted with reserve. To mention an instance,
— a case of sudden death from angina, said to be independent of dis-
ease of the heart, was recently communicated to me; but, from the
statements of the parties present at the dissection, it was clear that
there existed a marked dilatation, which they had not recognised.
Angina, however, in a moderate degree may, as Laennec main-
tains, exist independent of any organic disease of the heart or great
vessels, and it is, indeed, a very common affection. I have frequently
met with it in nervous or hysterical females subject to palpitation, in
nervous males, in cases of nervous dyspepsia and hypochondriasis,
and in mere plethora. It occurs in these cases under the form of oc-
casional aching pains in the anterior part of the chest, extending
sometimes to the neck and stomach, and attended or not with pain
and numbness in one or both arms. One of my medical friends al-
ways feels the affection of the arm when attacked with dyspeptic
palpitation, to which he is subject.
It is very conceivable that, if the irritation of a loaded and dys-
peptic stomach can create angina, an enlarged liver or other abdomi-
nal tumor, by displacing the diaphragm, or by mere sympathetic ir-
ritation, might, as in the cases of Dr. Latham, produce the same
effect.
Nerves affected in Angina. — M. Desportes places the seat of angina
in the pneumogastric nerve or par vagum, because the lungs, as well
as the heart, are affected with pain and have their function disturbed.
Laennec thinks that the filaments which the heart derives from
the sympathetic, are likewise implicated in the disease; because there
is sometimes pain in the organ without any in the lungs or material
embarrassment of the respiration. M. Bouillaud thinks that, as the
healthy heart does not appear to enjoy any animal sensibility (Bichat),
ANGINA PECTORIS NERVES AFFECTED. 465
the pain of angina is seated in the phrenic and intercostal nerves;
whereas, the nerves of the heart itself, simultaneously affected, re-
veal their morbid condition, not by pain, but by disturbances in the
movements of the organ, accompanied with that internal, undefina-
ble uneasiness which precedes faintness or syncope. Whatever be
the nerves in which the pain is seated, it is propagated, either by
sympathy or by anastomosis, to others: namely, to the superficial
cervical plexus and its anterior thoracic branches, whence proceeds
the pain in the neck and on the surface of the chest; to the branches
of the brachial plexus, especially the ulnar, whence arises the pain
descending to the elbow and sometimes to the fingers; finally, to the
branches of the lumbar and sacral plexus, whence the pain and numb-
ness felt in the thighs and legs, and even in the spermatic cord and
testicles.
The nature and variability of the symptoms of angina pectoris
confirm the opinion of Laennec that it is a neuralgic affection; for
those neuralgic affections whose nature is least equivocal, — sciatica
or tic douloureux, for instance, produce, in different degrees, effects of
the same nature and equally diversified as those of angina pectoris;
that is to say, acute pain, painful torpor, simple numbness in the
tract of the affected nerve, and sometimes spasm and sub-inflamma-
tory intumescence of the parts to which the nerve is distributed. I
have known malaria produce intermittent, periodic neuralgia, not
only in every extremity, but also in the heart.
Diagnosis. — The point of importance is, to ascertain whether there
be disease of the heart, and this is to be done by the signs fully ex-
plained in this work.
Prognosis. — When the malady is dependent on organic disease of
the valves, or of the great vessels, the prognosis is decidedly unfa-
vourable; for in addition to the danger which always attends the or-
ganic diseases in question, there is that of fatal syncope from the an-
gina— a termination to which this affection is prone. When angina
is connected with hypertrophy, or dilatation, I have generally found
it curable by the means prescribed for the latter diseases. When
the complaint is symptomatic of dyspepsia, hysteria, plethora, &c,
the prognosis is favourable.
Treatment. — When angina depends on organic disease of the heart,
it must be treated on the general principles which regulate the treat-
ment of the latter. The patient should instantly be placed in a state
of repose; flatus of the stomach, if present, should be extricated by
a draught of peppermint-water with anise oil, sp. setheris sulph. comp.
and aromatic confection: acidity should be neutralised by a free dose
of soda or prepared chalk; and if the stomach be loaded with an ir-
ritating mass of undigested food, it should be evacuated by ipecacuan
with sulphate of copper or of zinc, provided the state of the respir-
ation be such as to admit of the effort of vomiting. Should the dis-
tress be extreme and the patient plethoric, six, eight, or ten ounces of
blood may be drawn, either by venesection, or by cupping or leech-
466 HOPE ON DISEASES OF THE HEART.
ing on the precordial region. [The inter-scapular region is the pre-
ferable point for the application of cups. — P.]
These preliminary measures having been carried into effect as ex-
peditiously as possible, an antispasmodic and sedative draught should
be administered. It may comprise a full dose of tinct. or extr. opii,
or, as less exciting, of the liquor opii sedativus, or of acetate of mor-
phia, with sp. setheris sulph. comp. gss. and mist, camph. or solut.
asafoetid. gx. The draught and the other measures must be repeated
according to existing circumstances, of which the practitioner is the
only judge.
During the intervals of the fits, the general health must be improved
and the recurrence of the fit prevented by the same means as in or-
ganic disease of the heart.
When the complaint is chronic and the pain pretty constant, coun-
ter-irritants and derivatives, as blisters, setons, or issues on the prse-
cordial region, have been found useful. The emplast. belladonna is
also a valuable auxiliary.
In cases dependent on hysteria, dyspepsia, ansemia, &c. the primary
malady demands the first attention, while the neuralgic pain may be
combated by counter-irritants and occasional sedatives. The metallic
tonics, especially the sesquioxyd of iron in doses of from 9ij. to 1 §
thrice a day, and the M. Ferri C. in doses of 3iss, are the most effi-
cacious internal remedies for it. They act mainly by removing
anaemia, which frequently complicates, and even occasions, the hys-
teria, dyspepsia, nervousness and palpitation. Aloetic aperients and
animal food should be prescribed with the iron. Quina is the specific
for intermittent angina.
In angina dependent on plethora, bleeding and a restricted, dry diet
are the essential remedies. Dyspeptic or nervous symptoms must
be treated on the usual principles. (See Palpitation).
The remedy by which Laennec states that he has most frequently
succeeded in procuring alleviation in cases of angina pectoris, and of
neuralgia of the heart of a slighter kind and without radial ing pain,
is the magnet, which he employs in the following manner: he applies
two steel plates strongly magnetized, of a line in thickness, of an oval
form, and slightly arched so as to apply closely to the thoracic walls,
the one on the left precordial region, and the other on the opposite
part of the back, in such a manner that the poles may be exactly op-
posite and the magnetic current may traverse the part affected. This
remedy, Laennec adds, is fallible no less than all those by which we
ordinarily combat nervous affections; but it has succeeded in his hands
oftener and to a greater extent than any other. When it procures
little alleviation in angina, more may sometimes be obtained by ap-
plying a small blister under the anterior plate. "It should be remarked
that they who witnessed the application of the magnet by Laennec,
did not, in general, form so favourable an opinion of its utility as that
author himself. It appeared to be more successful when combined
with acupunctuation. I have not tried either, as they are calculated
merely to alleviate the symptom, rather than to cure the disease.
NERVOUS PALPITATION. 467
CHAPTER II.
PALPITATION, PARTICULARLY NERVOUS.
After presenting a general view of the nature and causes of pal-
pitation, and adverting briefly to its varieties, I shall dwell more par-
ticularly on palpitation from inorganic causes, usually called nervous.
As palpitation is, under all circumstances, dependent on over-ex-
citement of the nerves of the heart, the phenomenon, in its essential
nature, is always the same. The varieties which it presents arise
merely from differences in their causes, and from the different routes
which these causes pursue in order to arrive at and convey their
stimulus to the heart.
Thus, 1. the blood conveys the stimulus directly, and in three ways:
a. By arriving in excess, as from violent exercise, plethora, &c. I
conceive that palpitation from excessive loss of blood and all other
forms of anaemia or chlorosis, comes under this head; for, though the
quantity of blood be diminished, its remarkable attenuation enables it
to traverse the vessels with greater facility; and it probably, therefore,
arrives at the heart either in redundant quantity or with morbid ve-
locity. This view is more consistent than the anomalous one of pal-
pitation being produced, in cases of loss of blood and anaemia in general,
by a deficiency of the natural stimulus: an explanation which some
have offered. As anaemia always increases the nervous irritability,
this no doubt co-operates in producing anaemic palpitation, b. By
gorging the heart, in consequence of its transmission being impeded
by an organic disease of the organ, or an obstacle in some other part
of the circulation, c. By being of too stimulant a nature, in conse-
quence of the diet being exciting.
2. The nerves, on the contrary, convey the stimulus to the cardiac
plexus indirectly, as is the case in emotions of the mind, in dyspepsia,
in hysteria, &c. When the above two classes of causes co-exist, the
nerves and the blood may convey the stimulus conjointly.
Palpitation in general may be defined to be an increase in either
the force or the frequency, or in both the force and frequency, of the
heart's contractions, by which they become not only perceptible, but
sometimes very troublesome to the patient. They may vary in force
from a scarcely sensible degree, to a violence which is extreme. Not
unfrequently the sound of the beats is audible to the patient, especially
when lying on his side; and, in this position, the second as well as
the first sound may occasionally be perceived.
When the circulation is simply accelerated, as by exercise, &c. in
a healthy subject, the palpitation consists in an increase both of the
force and the frequency of the heart's action. The same occurs in
hypertrophy, and hypertrophy with dilatation. In dilatation with
468 HOPE ON DISEASES OF THE HEART.
attenuation, palpitation sometimes consists in an increase of the fre-
quency, but not of the strength of the beats, though the patient may-
experience the sensation of an increased impulse. Palpitation of this
kind is sometimes very obstinate. Laennec cites an instance in
which it lasted eight days, the pulse constantly beating 160 to 180
per minute. 1 have found the same remarks apply equally to sof-
tening.
It must be recollected that, in every organic disease of the heart,
when palpitation becomes extremely violent and prolonged, both the
impulse and the sounds may be diminished: — in other words, the
heart becomes gorged and incapable of adequately contracting on its
contents, sometimes yielding a struggling convulsive impulse, with
little sound and a feeble pulse, and, in an ulterior degree, especially
during dissolution, scarcely producing either impulse, sound, or pulse.
Suffocative dyspnoea, lividity, and extreme distress are always con-
comitant symptoms.
Palpitation from inorganic causes, usually called nervous, and imitating
disease of the heart. — There are few affections which excite more alarm
and anxiety in the mind of the patient than this. He fancies himself
doomed to become a martyr to organic disease of the heart, of the
horrors of which he has an exaggerated idea; and it is the more diffi-
cult to divest him of this impression, because the nervous state which
gives rise to his complaint, imparts a fanciful, gloomy and desponding
tone to his imagination. Members of the medical profession are
more apt than others to give way to these feelings; partly from their
apprehensions being more keen, and partly from an impression too
widely prevalent, that there is difficulty in distinguishing inorganic
from organic palpitation, and, consequently, that they must remain in
a state of anxious uncertainty. It may be said, for the consolation of
such, that the diagnosis presents no difficulty to one who, to general
signs, adds a knowledge of these afforded by auscultation and percus-
sion. I repeat this opinion with increased confidence in the present
edition, not only on the grounds of additional experience, but because
the signs both of organic and inorganic disease will now be found
much more precise and simple, in consequence of the new lights
thrown on particular valvular diagnosis and on inorganic murmurs.
Inorganic palpitation presents certain varieties, which it is of the
greatest practical importance to distinguish, as the treatment is diffe-
rent, and even opposite. It may be premised that, in all the varieties,
the palpitation will, cseteris paribus, be greater in proportion as the
patient is constitutionally of a more nervous, irritable temperament.
1. Palpitation dependent on dyspepsia, hypochondriasis, hysteria,
latent gout, mental perturbations either of the exciting or depressing
kind, excessive study with deficient sleep, and venereal excesses,
constitutes the first variety, and forms a large class. When from
these causes, it presents various degrees and characters. The slightest
degree of it I should describe, from having occasionally experienced
it, to be a tumbling or rolling motion of the heart, with a momentary
feeling of tightness and oppression. It is referable to an intermission
NERVOUS PALPITATION. 469
of the heart's action. In a further degree, as Abercrombie has well
described, there is a series of quick, weak, fluttering, irregular beats,
with slight anxiety, acceleration of the respiration, and a quivering
sensation in the epigastrium: this may last from a few minutes to half
an hour or an hour, and occur only at distant and irregular intervals,
or repeatedly during the day, especially when the patient is startled.
The next degree amounts to a perfect fit of palpitation, consisting in
increased impulse, sound and frequency of the beats, sometimes with
irregularity, and generally with more or less anxiety, dyspnoea, and
even orthopncea. The attack may be only occasional, or may occur
several times a day, or may even last with little intermission for
several days together.
The palpitation in question may be distinguished from that of dis-
ease of the heart, by the palpitation occurring only occasionally: by
its not being excited, but, on the contrary, relieved by corporeal
exercise of such a nature as would certainly disturb the action of a
diseased heart: by its disposition to supervene while the patient is
at rest, especially at the commencement of the night, when he lies
wakeful in bed; by a fluttering in the epigastrium; by the general
prevalence of nervous symptoms; by the affection being aggravated
when the nervous symptoms undergo an exacerbation; by the pulse
and the action of the heart being natural during the intervals between
the attacks; and by the absence of valvular and aortic murmurs, and
of undue impulse; "the shock, even when it at first appears strong,
having little real impulsive force; for it does not sensibly elevate the
head of the observer." (Laenncc).
To this category some would add, an increase of the palpitation
after meals, or when the stomach is deranged, and amelioration pro-
duced by dyspeptic remedies; but, as the stomach produces the same
effects when there is disease of the heart, these signs are not patho-
gnomonic of nervous palpitation. To this point I would particularly
direct the attention of practitioners; because many, in forming their
diagnosis of the affections in question, regard the dyspeptic signs as
paramount in value to all others, and are apt to refer to the stomach
the palpitation which really belongs to organic disease of the heart.
Though the present variety of palpitation is often attended with
various familiar nervous affections of the head, as pain or sensations
of heat or of cold confined to particular parts and coming and going
suddenly, temporary vertigo, tinnitus, and confusion of the sight, not
increased by lying or stooping; it is not, when purely nervous and
the patient not plethoric, accompanied with genuine signs of cerebral
determination or congestion: there is no universal, throbbing head-
ache with weight and tension, increased by stooping or the recumbent
position: no stunning sounds and pains in the head on suddenly lying
down or rising up: no permanent somnolency, apoplectic stupor, o>
regular apoplectic fits, as in hypertrophy, &c.
When it has been ascertained that the palpitation in question is in-
dependent of organic disease, the treatment presents no unusual dif-
ficulty, and is to be adapted to the nature of the exciting causes
12— d 31 hope
470 HOPE ON DISEASES OF THE HEART.
specified at the head of this division. It would be foreign to the sub-
ject of this work to dwell upon the particular remedial measures.
2. ' Palpitation from anaemia. I use this as a generic term, applicable
to both sexes and to all circumstances, instead of the specific term
chlorosis, which, before anaemia was understood as a general disease,
was applied to females with amenorrhoea, under a twofold error; first,
that the catamenial deficiency was the cause of the chlorosis, whereas
it is most commonly the effect; secondly, that the complexion was a
greenish yellow (*xcopo$); but 1 have assured myself by particular ob-
servations on upwards of 1000 cases, that the tint in question is no-
thing more than the residuary colour of the skin when the pink has
been withdrawn by anaemia; that the hue is more yellow or sallow in
females with dark complexions, and vice versa; and that it is equally
ob-ervable in males. This explanation is offered, because some wri-
ters still treat of anaemia and chlorosis as essentially different diseases.
In my opinion, there is no difference but in the cause, and it is proper
to state that such is the import which I attach to the term anaemia
throughout this work. Its causes may be, undue loss of blood in any
way, and whether sudden or gradual; draining diseases of any kind ;
deficient food, especially animal; bad air; chronic diseases of the ali-
mentary canal, lungs or heart: depressing passions; excessive intel-
lectual or corporeal fatigue: in short, anything calculated to deteriorate
the general health and impair the functions of assimilation and san-
guification.
The connexion between anaemia and affections of the heart and great
vessels was not noticed by Corvisart, Laennec, Bertinand Bouillaud,
Elliotson, or authors in general. In the first edition of this work, it
was shown by the experiments on dogs described above at p. 122,
that anaemia was not only a cause of palpitation, but ako of the inor-
ganic murmurs of the heart and arteries ascribed by Laennec to spasm,
and that it existed in almost all the cases in which Laennec described
these murmurs to occur. The palpitation which it occasioned consti-
tuted the main grounds on which 1 objected to the treatmentof Valsalva
and Albertini for hypertrophy, and substituted another treatment on
a less active depleting system. M. Bouillaud, as has been shown
above, (p. 143), has, in his more recent work, followed up the same
investigation and arrived at the same conclusions respecting anaemic
palpitation. It is, in fact, the variety which, when misunderstood, is
by far the most liable to be confounded with organic disease of the
heart.
The general symptoms ofanxmia may be rapidly sketched as follows.
— The complexion is unusually, and sometimes singularly, pallid or
exsanguine; the lips, the interior of the mouth, and the inside of the
palpebrae, partake more or less of the same paleness; the pulse is
quick, small, weak and jerking, (the pulse of -unfilled arteries,) and
during palpitation it often presents a thrill; its average frequency is
generally above 80 or 90, and under excitement it is easily raised to
120 or 130, and occasionally even to 140 and 150: the slightest
causes, including all corporeal rfforts, suffice to induce palpitation,
AN-EMIC PALPITATION. 471
breathlessness and faintness; whereas mere dyspeptic palpitation is
usually relieved by exercise; the body is usually constipated; there
is anorexia, with an especial distaste for animal food, and a predilec-
tion for sour articles, as acids, acid fruits, salads, &c; the catamenia
are deficient, and usually replaced by leucorrhcea; or, what is too
often overlooked, they are profuse, lasting; from six to ten days, con-
sisting of blood instead of the normal secretion, and, in fact, consti-
tuting a passive hemorrhage, which is often the cause of the anaemia;
the muscular system is very feeble, lassitude and aching pains of the
limbs being produced by trifling exertions; the intellectual powers
and energies are also greatly impaired; in many patients, there are
transitory neuralgic stitches and aches in various parts of the body,
and sometimes exquisite sensitiveness of the skin, especially that of
the mammae and abdomen; more or less headache is almost always
experienced, generally with veriigo, rushing noises in the ears, and,
in severe cases, with intolerance of light and sound, delirium, and
even fatal coma, of which I have recently witnessed two instances.
Such are the general signs of anaemia, and therefore of anaemic palpi-
tation.
We proceed to the physical signs. The impulse of the heart is less re-
markable for force, than for an abrupt, bounding character, with throb-
bing of the arteries — often universal, and a jerking pulse. Hence, this
species of palpitation is more audible to the patient than perhaps any
other, the sound appearing to rush through his ears, especially when
he lies on his side in bed, and each arterial throb causes a movement
of his pillow. Some are so sensible of the universal anerial throb,
that they can count the pulse by the mere sensation, particularly as
experienced in the back, when resting against a chair.
When the anaemia is considerable, palpitation occasions a weak,
soft bellows-murmur in the aortic orifice,1 with the first sound; and
a corresponding whiff is heard in the carotids, subclavians, brachials
and other considerable arteries, especially when slightly compressed
with the edge of the stethoscope, though this is not always essential
to the production of the phenomenon.
[In the anaemic condition, a bellows-murmur is often heard near the left
nipple, even when no abnormal sound can be detected at the aortic valves;
thus proving, that the regurgitation takes place through the mitral orifice. — P.]
These murmurs in the heart and arteries occur whenever the action
of the organ is excited, and in some patients the slightest causes suffice
to produce the excitement; as, for instance, a momentary mental emo-
tion, a change of posture from the recumbent to the erect, a con-
strained position, a meal, flatus in the stomach, &c. I have often
found the phenomenon to subsist for a few seconds or minutes only;
that is, so long as the exciting cause continued in operation. The
1 It might be expected in the pulmonic orifice also; yet I have not been able
to satisfy myself of its existence in this situation. Some cases, however, at
present under my care, lead me to think that the point is open for farther in-
vestigation,
472 HOPE ON DISEASES OF THE HEART.
patient, if asked whether he is conscious of palpitation, invariably
replies in the affirmative; yet the pulse may not be strong — it may
even be small and weak; but it will always be "jerking." It is the
velocity, therefore, and not the power of the heart's contraction,
which, operating on attenuated, aqueous blood, is the active instru-
ment in occasioning the murmur. This subject has already been
fully explained (P. 124).
Another phenomenon invariably attends the inorganic murmurs in
the heart and arteries, and may even result from a slighter degree of
anaemia. I allude to the venous murmur in the jugular veins, parti-
cularly the internal. This has already been fully described, (p. 129),
and it has been shown that musical hums and whistles, ascribed by
Laennec and Bouillaud to the arteries, are really referable to the veins.
For the diagnosis of ansemia from valvular murmurs of the heart,
the reader is referred to p. 372. The signs there explained, taken in
connexion with the general symptoms of anaemia, divest the diagno-
sis of all difficulty.
Anaemia often complicates dyspeptic, hysteric, and nervous palpi-
tation, and that from organic disease of the heart. In all cases, it is
of the utmost importance to detect it: as, unless there be insuperable
contra-indications, it always requires a degree of the treatment de-
scribed below.
The treatment of anaemic palpitation is simple, certain, and satis-
factory. The operation of the exciting cause having been suspended,
the never-failing remedies, unless there be counteracting complica-
tions, are, large doses of any of the stronger preparations of iron,
continued for three to six or eight weeks; with aloetic aperients, to
maintain a free, but not relaxed state of the body; and a large pro-
portion of animal food, especially mutton and beef, lightly dressed,
and taken twice a day at an interval of not less than six hours. A
dry, bracing air, a change of air, and out-door exercise short of fa-
tigue, are valuable auxiliaries.
3. Palpitation from too stimulant diet. This 1 have observed to
be a very common affection amongst medical students coming from
active avocations and a full diet of animal food, porter and wine, in
the country, to sedentary, studious habits in London, without making
a change to a lighter diet. 1 have noticed the same in Oxford and
Cambridge men, in young barristers and attornies, and in various
others under analogous circumstances. After a few weeks, a state
of febrile excitement comes on. The pulse is accelerated and full;
the tongue is whitish; the body confined; the skin hot; the face
flushed, with throbbing headache and sometimes universal throb-
bing. The nervous system is very excitable, so that palpitation is in-
duced on slight exertion, mental emotion, &c; and it is principally
this which excites the alarm of medieal students.
A single bleeding, a few smart cathartics, and a broth or fish diet for
a week or ten days, easily removes this affection. The diet should
subsequently be more moderate, with considerable restrictions as to
malt liquors, wine, &c.
PALPITATION. 473
4. Palpitation from plethora. This occurs principally in those who
have a decided plethoric tendency. After living loo freely, or re-
linquishing active habits without a reduction of diet, and sometimes
without any very obvious cause, the patient becomes stouter than
usual, and complains of palpitation, or undefinable oppressions in the
precordial region, sometimes with slight angina pectoris; these symp-
toms are increased by exertion, mental excitement, and often by meals;
the pulse is small and oppressed; the spirits dejected, sometimes with
vague fears or dread of death; constipation and dyspepsia generally
attend, — the latter sometimes inflammatory. The symptoms pro-
ceed from a gorged state of the heart and whole vascular system.
The diagnosis is formed by the absence of all the usual physical
signs of organic disease of the heart. In consequence of the feeble-
ness of the pulse, I have often seen the complaint mistaken for nervous
debility, and treated ineffectually with tonics.
The most prompt relief is afforded by bleeding to the extent of
eight or ten ounces; which, by removing the vascular tension, restores
fulness and strength to the pulse, and often dissipates the angina at
once. The depletion may be repeated, if necessary, once or twice,
at intervals of two or three weeks. Meanwhile, aperients should
be employed, and the diet restricted and regulated according to the
dyspeptic sympioms. Dyspepsia is, in fact, a most salutary check on
immoderate feeding in those who have a decidedly plethoric tendency,
for whom a singularly small quantity of food is generally sufficient.
Such are the principal varieties of inorganic palpitation. So com-
mon are they, that, of those who consult in private practice for sup-
posed organic disease of the heart, I have found at least one half to
be exempt from that malady.
Inorganic and organic causes of palpitation not unfrequently coexist,
and the discrimination of both is of great importance, as the treat-
ment must undergo corresponding modifications. The practitioner
who is well acquainted with the signs of each separately, will expe-
rience little difficulty in recognising the two when combined.
The following cases are added, as exemplifying more graphicallv
than can be done by mere description, a few both of the combined
and the separate varieties.
Dilatation with Hypertrophy; ever-feeding; simple Apoplexy . — A young
medical gentleman was subject for four years to dyspeptic symptoms
and palpitation of the heart. They commenced about six months
after leaving school, where, while growing rapidly, he had been ac-
customed to very violent exercises and exertions. When he became
an apprentice, his appetite was very great. He ate large quantities
of animal food, and never took any kind of exercise. His first symp-
toms were a heavy pulsating pain in the back of the head, extending
forwards to the forehead, aggravated by any sudden motion, particu-
larly that of rising up or lying down; giddiness, and disinclination to
any exertion, sleep constantly disturbed by frightful dreams, particu-
larly if the head was not much higher than the body; shortness of
breath and palpitation on going up stairs or up a hill; a weak flutter-
31*
474 HOPE ON DISEASES OF THE HEART.
ing pulse when agitated or startled, accompanied by a sensation of
weight and fulness about the heart. These symptoms continued for
about three months, when he had a fit of congestive or simple apo-
plexy, for which he was bled, blistered and purged. He now fell
greatly into the habit of rowing, and made long and violent exertions
in matches, &c; but he was always short-winded during the effort,
and after it suffered from palpitation. At this time he entirely lost
his appetite; his fingers were blue, and very generally dead, particu-
larly in the mornings, and his pulse feeble. He was seldom without
heart-burn after any meal, and when this was the case he suffered
more from palpitations, dreams, &c, and his fingers were more con-
stantly dead. His feet also were nearly always dead, sometimes
through the whole night. His bowels were irregular and costive,
and skin cold and damp. By being bled occasionally when the affec-
tion of the head became worse, by abstaining from all violent exer-
cise, paying attention to diet, correcting dyspepsia by occasional
stomachics and antacids, and keeping the bowels open, he completely
recovered from the above symptoms within four years from their
first appearance, not having employed any systematic medical treat-
ment for the first two. In the course of a year and a half after the
commencement, he had few symptoms remaining, and he considered
himself quite well, never having any return of palpitation but when
he had heart-burn, or had been taking too violent exercise.
In this case, the dyspeptic and congestive symptoms were super-
added to hypertrophy with a predominant degree of dilatation, as
indicated by auscultation and percussion. Mere nervous affections
of the heart, without plethora, never present the marked symptoms
of cerebral determination exhibited in the present instance.
Eight years have elapsed since the preceding case was written.
From a premature return to active habits, the patient had two recur-
rences of simple apoplexy. For the last six years, his enlargement
of the heart has been cured, and he has enjoyed exemption from all
his old symptoms.
Dyspeptic and Nervous Palpitation, with Dilatation and Cerebral
Congestion. — A gentleman, set. 40, has from his youth been very sub-
ject to febrile and inflammatory affections, and, though active, he has
always been rather short-winded on ascending. He is subject to
starting from sleep, in consequence of which he awakes shouting out
violently, and always finds himself in a fit of palpitation and great
agitation. When merely awakened from sleep by his attendant, he
always starts suddenly and in the same state of agitation. For at
least ten or fifteen years, he has always experienced great confusion in
the head on first lying down to sleep: so much so, that he has seldom
ventured to retire to bed alone. The same uneasy sensations have
occurred on awakening in the morning, and he has always required
a quarter of an hour to compose himself before rising. Hence, he
has always had a dread both of going to bed and of getting up. He
has about eight times had a kind of fit, that is, an indescribably
distressing universal sensation, as if he were dying, invariably accom-
PALPITATION — CASES. 475
panied with palpitation and gasping, and terminating in partial un-
consciousness, though without any convulsive movements. After
an attack of this kind he immediately recovers the perfect command
of his faculties. He has never had any paralytic sensations, though
he is subject to tingling of the fingers, to a tremulous sensation of the
left side and extremities, and to sleeping of the feet. He has occa-
sionally experienced optical illusions, and once lost his sight com-
pletely, as if a blanket had fallen before his eyes.
He is subject to a throbbing pain in the posterior part of the head,
which is one of his most distressing symptoms, and to acidity and
excessive flatulence. A load of undigested and acid food is more apt
than any other cause to bring on the fit described, and it is immedi-
ately relieved by an emetic, and sometimes even by a large dose of
soda. Bowels regular, but evacuations generally unnatural.
Until three years ago, he was in the habit of being cupped on the
nape of the neck every three or four months, and experienced great
relief from the depletion. Since that time, it has been less necessary,
and has only been resorted to occasionally.
The patient gets rid of nearly all the inconvenient symptoms when
he pays strict attention to diet and regimen, and relieves the circu-
lation by cupping when the cerebral symptoms indicate it.
This is a case in which the symptoms were so closely connected
with stomachic derangement that they were long supposed to result
from the latter cause exclusively. The nature of the cerebral symp-
toms, however, and the evidence of dilatation afforded by auscultation,
remove all doubt as to the real nature of the complaint. Since the
preceding was written, eight years ago, the patient has enjoyed un-
usually good health.
Dyspeptic, Hypochondriacal, and Nervous Palpitation. — A gentle-
man, aet. 22, rather dyspeptic from his youth, became affected with
permanent depression of spirits from a mental cause. This was
followed by excessive torpor of all the functions both corporeal
and mental. Dyspepsia manifested itself in its most aggravated
form, while the mind, naturally energetic and powerful, became ob-
tuse and totally incapable of exertion, and the spirits sank into a state
of apatiietic despondency. With these sj'mptoms he experienced
palpitation on the slightest exertion or emotion. It sometimes con-
sisted in merely a few rolling or tumbling movements of the heart,
attended with a sensation of fulness and oppression; at other times,
the organ fluttered and faltered for several minutes, or for a longer
perioJ, the pulse being small and feeble, and exhibiting the same un-
steadiness; at other times, again, the palpitation amounted to a violent
paroxysm, accompanied with gasping and orthopnea. During the
intervals of the attacks, he was neither short-winded nor subject to
palpitation, and he invariably improved by exercise, which he is ca-
pable of taking to a great degree.
He was subject to occasional, temporary, local pains in the head,
with stupor, somnolency, and sometimes with visual illusions.
This patient, after suffering for upwards of four years, almost com-
pletely recovered, by a removal of the mental depression, by travel-
476 HOPE ON DISEASES OF THE HEART.
ling as a pedestrian, by an abstemious dyspeptic diet, by strict attention
to maintain regularity of the bowels, by combating fits of dyspepsia
immediately on their appearance,(for which evacuation of the stomach
by an emetic, followed by abstinence and an aperient, were the most
efficient remedies), and by pills consisting each of a grain of sulphate
of iron, one of aloes, and three of comp. cinnamon powder, taken to
the extent of one or two whenever the bowels were torpid, a lave-
ment being employed when the pills failed.
In this case, the sounds and action of the heart were natural, except
during the attacks of palpitation. The cerebral symptoms were partly
nervous, and partly those of a languid circulation through the head,
but not of increased determination to it.
The state of the patient's health has continued to improve up to the
present date.
Plethoric Dyspepsia, with Palpitation. — A medical gentleman, get.
35, consulted me in 1838. Very stout and plethoric, became subject
to indigestion, with slight dyspnoea, palpitation, and headache.
Bleeding invariably relieved these symptoms, and, for a time, made
him feel light and comfortable. This condition having continued
for ten months, during which period he became much stouter, he
was attacked, one morning, on going out, with palpitation, consisting
of quick, weak, irregular, and fluttering beats of the heart, with
dyspnoea and anxiety. Was not relieved by aether and ammonia,
and, as he felt numbness in the right hand, which created apprehen-
sions of apoplexy, he was bled to thirty ounces, but with little imme-
diate relief, as the attack of palpitation continued for two hours.
During the ensuing month, he experienced heart-burn, with a "con-
sciousness of having a stomach during digestion;" pimples on the
tongue; headache, and dyspnoea on ascending. Always felt better
after taking aperient and stomachic draughts, even though the body
was previously regular. Stated that, being subject to thirst, he had
been in the habit of drinking very freely of water and slops; from
malt liquors, wine, &c, he had wholly abstained, as they excited him.
Had always been a moderate and plain eater. Auscultation proved
the heart and lungs to be sound.
I considered the symptoms, in this case, to depend mainly on
vascular plethora, though mental emotion had probably contributed.
I desired him to abstain, to the utmost, from liquids; to restrict his
meals, especially dinner, still more, and to be bled to six or eight
ounces occasionally; also to take an alterative aperient pill on
alternate nights, and a bitter aperient and antacid draught thrice a
day. He speedily improved, and has enjoyed good health up to the
present time, that is, upwards of a year.
Plethoric Congestion of the Heart, with Palpitation and slight
Dyspepsia. — C n,. Esq., aet. 40, plethoric and red; (13 stones);
has gained two stones in the last two or three* years. Eats eight
ounces of meat at breakfast and more at dinner, and drinks about
half a pint of wine.
Habits sedentary; that is, writes six or seven hours per day; where*
as he formerly had much more exercise.
PALPITATION CASES. 477
Complains of a feeling of oppression about the heart, as if it could
not contract, or "as if there were a stoppage there." Occasionally
has a feeling of something tumbling or bounding in the part (the
systole following an intermission). These sensations render him very
uncomfortable, yet he can walk up hill and up stairs without dys-
pnoea or palpitation.
Tongue white, furred; occasionally a little distention of stomach
after meals, but no other symptoms of dyspepsia. Bowels, regular
daily. Pulse, small, weak and oppressed. No head-symptoms except
occasional vertigo and increased nervous irritability, — being much
more upset than formerly by any business of a public nature.
Auscultation. — First sound very weak, and second weaker than
natural, allowance being made for obesity.
Remarks. — Here, the heart and whole vascular system were over-
distended, so that the organ could not contract freely and fully.
The case shows an incipient degree of functional disturbance of the
heart.
He speedily recovered under purgatives, a limited and less stimu-
lant diet, and the use of liq. potassae as an absorbifacient.
Plethora; dyspepsia; hepatic enlargement; jaundice; intermission; pal-
pitation; "fulness" of the heart; and fainting. — The subjoined letter,
graphically descriptive of his own case, is from an eminent practi-
tioner in one of the provincial towns, who laboured under inter-
mission of the pulse, resulting from the anxieties of an active and
powerful mind, and the irregularities of diet and hours, inseparable
from a very large and successful practice. He has consulted me at
intervals since 1834, but on no occasion presented physical signs of
organic disease of the heart. He is of a sanguine, excitable tem-
perament, and rather plethoric habit.
"January 18, 1839.
"My dear Sir, — I think you will feel some interest in a brief his-
tory of your quondam grateful patient, with supposed affection of
the heart, since he last consulted you.
" On returning into the country, I determined, as far as my prac-
tice would permit me, to conform to the directions you kindly gave
me. I rode less on horseback, I got an active assistant, I sat up less
at night, I determined on meeting anxieties with a firmer front, and
I married. Still, my dear doctor, the unruly heart jogged on very
interruptedly. I began to feed, as happy husbands do, till I made
my ten stone five pounds, as it was when you last saw me, into
twelve stone nine pounds. I indulged in shooting a little each sea-
son, and hunting sometimes — always increasing thereby the palpi-
tation and irregularity, yet, otherwise, with decided benefit to my
health.
"I believe that, till within the last month, I was never able to
count eighty beats without interruption, and more generally the in-
terruption occurred every five or six beats. There was also consi-
derable pulsation in the jugular veins, and a marked increase in their
478 HOPE ON DISEASES OF THE HEART.
volume. After exhaustion or privation of sleep, there was the saw-
sound in the region of the heart, audible to my wife. You may sup-
pose that, during this period, I often reflected on the necessity of
putting my house in order, and really calculated on great diminution
of ' length of days.' On ascending a hill or a long flight of stairs,
I have often felt as though I must there die; and have very often
been asked by attendants if I was not very ill. Twice I actually
fainted — which you will imagine, with my knowledge of the cause,
must have been most distressing. I have on many occasions re-
quested that Mrs. would take the opportunity of feeling my
pulse whilst sleeping, to ascertain if it was then irregular; — thinking
that, when it was working without the influence of the fears of an
anxious mind, alive to the dangers of the supplies being not only
suspended, but actually cut off, it might beat regularly. No! she
found the irregularity still the same!
''For some months back, I have frequently suffered pain in the
liver and right shoulder, with indigestion and acidity of stomach;
and, a week before this Christmas, I was seized with inflammation
of the pyloric end of the stomach, and (I suppose, from the seat of
the pain and the uneasiness on anything passing from the stomach)
duodenum. Jaundice came on in two days, and I was confined to
bed nearly a fortnight.
"A few days after the commencement of my illness, 1 bethought
me of the old enemy, the heart, and felt my pulse: — when, to my
great astonishment, it was, though quick, perfectly regular! Many
times in that day, I found the same happy regularity. In a fortnight
I left home, to avoid the plague of being consulted before I was able
to do my duty, and went on a visit to a gentleman who farms his
own estate, and there, with some precaution, indulged in my favourite
amusement of shooting. On the second day I found I could mount
the hills as well as my friend, bag more game, and bear the same ex-
ertion with apparently less fatigue: — and all without my old pest,
the < bad heart.'
"It is now a month since I was taken ill, and I believe no day has
passed, up to the present, without my examining (be assured more than
once) my old enemy, to see if he was vanquished, nor have I once
detected any irregularity in the heart's action. The miserable fulness
about the heart has left me. I can walk up stairs without fatigue,
and, returning from — — to-night, I ran a mile to ascertain whether
that would produce the interruption; but all, thank God, is once more
quite right.
"1 took small doses of calomel, under Dr. 's direction, during
the acute. part of the attack, and also mild saline aperients; but it is
worth while to remark that, during my illness, I have lived most ab-
stemiously. I have avoided my besetting sin, coffee drinking; also
wine and beer; have reduced my animal diet very considerably, have
avoided strong tea, taken daily some walking exercise, and am re-
duced fourteen pounds in weight.
"My grateful feeling for your former kindness has induced me to
PALPITATION — CASES. 479
trouble you with this narrative, hoping you may find some interest
in it. At your leisure, I should be very happy to hear from you," &c.
1 heard from the writer three months after the date of the preceding
letter, and he continued "enjoying a perfectly regular pulsation and
excellent health and spirits." The saw-sound had ceased.
Remarks. — This is a striking instance of the extent to which func-
tional derangement of the heart may proceed in a plethoric individual,
over-excited by intellectual exertions, and by too full stimulating a
diet, taken at irregular hours.
I have repeatedly heard the arterial murmur, (the saw-sound of my
correspondent), during states of excitement, in individuals of the san-
guine temperament, even though not anaemic; for their blood is na-
turally thinner than that of melancholic temperaments. I presume,
therefore, that this was the cause of the phenomenon. It did not exist
when I examined him. ♦
The good effects of the reducing treatment employed for the gastro-
duodenitis and icterus, strikingly display the advantages of effectually
disgorging the whole vascular and hepatic system in such cases.
The following case is analogous to the preceding.
Plethora; bilious engorgement; intermission of the pulse; occasional
fainting; great oppression and debility. — A lady, aet. about 40, of large,
full habit, consulted me for supposed disease of the heart in 1S38.
The pulse was feeble, and presented three or four intermissions per
minute. She felt great oppression in the praecordial region, with
faintness, — especially on lying down. She was totally unable to
ascend a flight of stairs, as the effort produced overwhelming faint-
ness, with fluttering palpitation, &c. I discovered no physical signs
of organic disease of the heart; but, on examination, I found the liver
enlarged, and the alvine evacuations bilious. During the whole pre-
vious year, she had experienced great constipation.
Active mercurial purgatives, employed almost without intermission
for two months, brought off an incredible quantity of dark green and
deep orange bile. If the medicine was at any time suspended for a
couple of days, for the purpose of examining the evacuations unin-
fluenced by calomel, she felt worse — nor were the motions exempt
from bile. Her diet was principally veal and chicken broth, and
farinaceous articles. At the expiration of two months, the evacuations
were healthy; all intermission, palpitation, and faintness had ceased;
and, though thinner and paler, she felt light and active, and ascended
a long staircase with perfect ease. I saw her three months afterwards
in the enjoyment of perfect health — "much better than she had been
for years."
Remarks. — The symptoms, in the present case, were mainly de-
pendent on the poisonous effects of bile; but the reduction of plethora
probably contributed to her restoration. Bilious accumulations in
plethoric free livers, with constipation, are very apt to be overlooked;
and supposed debility often scares practitioners from adequate purging,
even if they are not deterred by imaginary disease of the heart. The
480 HOPE ON DISEASES OF THE HEART
advantage of good diagnosis of cardiac disease in such cases, is obvious:
without it the practitioner is timid and undecided.
The following case is another aspect of an analogous affection.
Derangement of the stomach, bowels, and liver: paroxysm of
palpitation with orthopnoza. — A distinguished surgeon of the me-
tropolis called on me late at night, in 1834. As I happened to be
out, he returned home, passed a sleepless night in a state of orthopncea,
with great precordial oppression, and sent for me very early on the
following morning. 1 found the pulse and action of the heart to be
small, weak, irregular, intermittent, and unequal, in as great a degree
as I have ever seen them in the worst cases of disease of the valves.
He was in alarm lest rupture of a valve or great vessel had taken
place, as the symptoms had supervened rather suddenly.
On careful examination, I found the sounds and impulse of the
heart perfectly natural, except the irregularity. The complaint was
traced to unusual professional exertions, with too full and indiscri-
minate a diet, which had deranged the alimentary mucous membrane
and the liver. An active mercurial cathartic afforded almost imme-
diate relief; and alterative aperients, a restricted diet, and light antacid
bitters, restored him to perfect health in the course of ten days. He
has not subsequently had any recurrence of the same affection.
CHAPTER III.
SYNCOPE.
Opposed to the state of over-excitement of the nerves of the heart,
which we have been considering in the last chapters, is that of defi-
cient excitement, the extreme degree of which constitutes syncope.
Numerous agents have the effect of reducing, and even completely
suspending, the contractile power of the heart. Such, for instance,
are the depressing passions, feelings of disgust, certain scents, pain,
violent shocks of the nervous system from accidents, sudden loss of
blood, suddenly raising the patient to the erect position in cases of
great anasmia; congestion of the heart from obstacles to the circula-
tion; stupifying poisons, as hydrocyanic acid, digitalis; certain mi-
asms, as the plague, Indian cholera, pestilential fever; any agents, in
short, which can, directly or indirectly, suspend for the moment the
excitability of the heart
The phenomena of syncope are two well known to require descrip-
tion: it may be said summarily that they are those of sudden death,
except that, in most cases, though not in all, the patient can be re-
stored to life. The ordinary duration of syncope is from a few seconds
to a few minutes ; but in certain rare cases it lasts for hours and even
days, sometimes imitating death so perfectly as to lead to the horror-
striking accident of living inhumation. In such cases, however, the
SYNCOPE. 4S1
action of the heart is not wholly suspended, though exceedingly fee-
ble. I imagine that the second sound would be heard with the ste-
thoscope, though possibly the first might not. In ordinary cases of
syncope, the unconsciousness is seldom complete, and, though the
pulse be imperceptible, feeble sounds of the heart's action may in ge-
neral be distinctly heard. The latter is sometimes the case in indi-
viduals, who, after immersion in water, or other causes of asphyxia,
exhibit no apparent signs of life. Under these circumstances, there-
fore, auscultation should invariably be employed; for, so long as the
sounds are heard, the patient is perfectly within the possibility of
recovery.
Syncope, though free from danger when purely nervous, is a for-
midable accident when accompanying organic disease of the heart,
as it is apt to terminate in sudden death, being, in fact, less the cause
than the symptom of a fatal suspension of the circulation. This ca-
tastrophe is more liable to occur when angina pectoris is superadded
to organic disease; in consequence, apparently, of the lesion being
double, the motive principle as well as the muscular apparatus of the
heart being inadequate to the discharge of its function. Sudden
death is also apt to occur from syncope of anaemia, especially when
the patient is suddenly raised erect.
Treatment. — The ordinary excitants, which suffice for so slight an
affection as purely nervous syncope, are, the horizontal position with
the head low, fresh air, the sudden aspersion of cold water, startling
the patient by a sudden noise or blow, ammonia and other pungent
errhines. When syncope is symptomatic of another disease, it re-
quires that, in addition to its ordinary treatment, remedies should be
employed, adapted to the nature of the primary affection. The prin-
ciples according to which this must be done in reference to disease
of the heart and angina pectoris, have been explained in the preceding
pages. In extreme cases of anaemia, the patient should be kept con-
stantly in the horizontal position, till the tendency to fainting has
ceased. This remark applies to those more especially, who have
sustained a great loss of blood. The treatment of anaemia has been
summarily described in the preceding chapter, p. 472.
12— e 32 hope
PART V.
MISCELLANEOUS AFFECTIONS.
These affections consist of a few which are not reducible to any
of the preceding heads.
CHAPTER I.
POLYPUS OF THE HEART.
The concretions of blood commonly called polypi of the heart and
great vessels have given rise to much discussion, and various doctrines
respecting them have successively superseded each other in the schools.
According to some, they are merely coagula of blood formed after
death: according to others, they are organized substances, formed be-
fore death, and analogous to nasal and uterine polypi: others, again,
believing that both kinds existed, denominated the former false and
the latter true.
It was a very general opinion during the last century, that polypi
produced all the symptoms which are known to result from organic
disease of the heart: while some, on the contrary, doubted whether
the}'- produced any symptoms whatever. The researches of Corvisart,
Testa, Burns, Kreysig, Laennec and succeeding pathologists have de-
cided the question, and have fully established the fact, that there are
some polypi formed during and after dissolution, and others formed
for a longer or shorter period anterior to it, presenting various de-
grees of organization, and the cause of certain well-marked symp-
toms during life. These facts have more recently been corroborated
by Bouillaud, who gives the results of sixty-five cases seen by him-
self, M. Legroux, or others (Traite, ii. p. 592, 1835).
That polypi should form before death, might be anticipated a priori
from the fact that, in the arteries and veins, blood can coagulate
during life, and, becoming organized and adherent to the walls, ob-
literate the canal of the vessel. Instances of this have, of late years,
been accumulated in abundance by Hodgson, Burns, Kreysig, Bertin
and Bouillaud, Laennec, Velpeau, Cruveilhier, Mr. Arnott, Dr. Ro-
bert Lee, and the writer: in short, there is scarcely a single conside-
rable vessel, especially a vein, in which the concretions in question
have not been found. In veins, they are a well-known cause of par-
tial dropsies;1 as the white swelled-leg or phlegmatia dolens, from
obliteration of the femoral vein.
1 Vid. M. Bouillaud Archiv. Gen. de Med. torn. ii. et v.
POLYPUS — ANATOMICAL CHARACTERS. 483
It has long been known that polypi are of more frequent occurrence
in the right, than in the left, side of the heart: M. Bouillaud adds, on
the faith of the cases which he adduces, that they are also more fre-
quent in the auricles than in the ventricles. The principal cause of
this evidently is, that the blood is more easily retarded and rendered
stagnant in the right cavities, and that it is in them especially that it
accumulates during the last period of life and after death. M. Bouil-
laud is of opinion that other causes also may explain the circumstance:
such as, the frequency of phlebitis which is sometimes propagated
even into the right cavities; perhaps, a more marked tendency to
coagulation in the venous, than in the arterial blood, &c. (Traite, ii.
60S).
Anatomical Characters of Polypi. — These will be rendered more
simple by considering the polypi as, 1. unorganized, 2. slightly or-
ganized, and 3. more completely organized.
1. Unorganized Polypi. — Polypi formed after death, or during
the last moments of life, are concretions of hbrine, which, if very
recent, merely overspread portions, but seldom the whole, of the clots
of blood in the heart and great vessels with a thin translucent layer
resembling inflammatory buff: but, if rather older, they constitute
larger and thicker masses, often entirely independent of the red clots
of blood. In dropsical subjects, or when the blood is very serous,
the fibrine appears as it were infiltrated, and is soft, trembling, and
semi-transparent like jelly. Polypi of the above kinds are far more
common on the right side of the heart than the left; they do not ad-
here to the walls; they are of a uniform semi-transparent yellowish
or whitish colour; and they do not present any trace of internal or-
ganization and structural arrangement: by these characters they may
be distinguished from polypi formed some time previous to death.
2. Slightly organized Polypi. — It may be premised, as a fact as-
certained by observation, that fibrine, separated from the blood and
become concrete in a living organ, (whether the heart, the blood-
vessels, or serous, cellular, or other tissues into which it has been ex-
travasated), retains its vitality and is susceptible of organization in
an equal degree with inflammatory lymph.
Polypi formed some time before death, in which this organization
has commenced, are of a much firmer consistence; more opake, and
less charged with serum; their fibrous texture is more distinct; they
are often arranged in concentric layers; their colour, instead of being
uniformly whitish or yellowish, has in parts a pale flesh tint some-
times slightly violet, from incipient vascularity; they are found more
frequently on the left side of the heart than recent polypi are; and
they adhere more or less firmly to the walls of the heart, from which
it is scarcely possible to draw them away in a single piece, as the ex-
tremities remain attached under the columnae carneae. The medium
of adhesion is often a filamentous tissue, the rupture of which leaves
a roughness both on the lining membrane of the heart and on the sur-
face of the polypus. The surface also presents spots of blood pene-
trating more or less deeply and sometimes ramifying inwards, as if to
484 HOPE ON DISEASES OF THE HEART.
form vessels for the purpose of organizing the mass. Some of these
polypi contain pus in the centre, sometimes pure, at others, curdy or
sanrous — precisely what we so commonly see within coagula formed
by phlebitis (see the writer's Morbid Anat. Figs. 204 and 240). The
globular vegetations of M. Laennec (De l'Auscult. ii. p. 530) are, in my
opinion, nothing more than varieties of these suppurating polypous
concretions. They present themselves under the form of irregularly
spherical or ovoid balls or cysts, the size of which varies from that
of a pea to that of a pigeon's egg. The cysts are smooth externally;
and their walls, which scarcely exceed half a line in thickness, are
composed of an organized substance somewhat firmer than the white
of a hard-boiled egg, and resembling in opacity the oldest polypous
concretions. The internal surface of the cyst is less smooth than its
exterior, and appears formed of a softer substance, which sometimes
gradually degenerates, in the direction from without to within, into
a matter similar to the contents of the cyst. These contents, in the
cysts which there is reason to believe the most recent, are bloody; in
the older they are like lees of wine, and in the oldest they are puri-
form. The cyst adheres by a pedicle, which, according to M. Laen-
nec, is of more recent formation than the cyst itself, being more trans-
lucent, and in a less advanced state of organization. The pedicle is
interlaced amongst the columnar carneae, and united more or less
firmly with the internal membrane. The most, common situation
for these bodies, and where I have frequently found them, is about
the apex of the ventricles. 1 am not aware that they are ever found
in the great .vessels: I have never seen them there.1
i Respecting the source of the pus within polypi, M. Bouillaud gives the fol-
lowing opinion. "Various authors, and M. Legroux in particular, regard this
pus as a product of inflammation of the concretion which contains it. « An in-
flammatory movement,' says M. Legroux, shows itself in the concretion ....
it softens in the centre, becomes granulated, passes to the sanious, then to the pu-
rulent state: subsequently, the pus is absorbed and there only remain the exterior
layers of the concretion, which have resisted the softening, and which form the
walls of the abscess, or the cyst.' As for myself, pursues M. Bouillaud, I think
that such is not the ordinary origin of the pus which is found in concretions,
this pus appears to me to have been either secreted in the cavity of the heart:
or to have been transported thither by absorption, and then to have occasioned
the formation of a coagulum which has entirely enveloped it. At the period
when pus in the centre of a concretion is most frequently found, the concretion
presents scarcely the rudiments of organization, and one can hardly conceive
how, in this stage, it could undergo an inflammation characterized by purulent
secretion. I do not pretend to say, however, that, when once well organized,
sanguineous concretions may not inflame and suppurate. Nevertheless, this is
not, if I do not mistake, a very common occurrence," (Traite, ii. p. 610.)
To myself, the opinion which ascribes the pus to inflammation appears the
more probable, as being more in accordance with the suppuration of coagula
which we constantly see in phlebitis, and also because I think that pus in the
circulation would be mixed equally with the blood, and not collected in parti-
cular points, as supposed by M. Bouillaud's theory. I do not even believe that
what are called purulent depositions in organs really consist of particles of pus
deposited by the blood; but that pus poisons the blood, and occasions its coagu-
ation and suppuration in the spots affected. In this point of view, I do not
POLYPUS CAUSES. 485
3. More completely organized Polypi — There are other polypi which
appear to be of still older formation, and which may probably be
dated as far back as several months prior to the death of the patient.
They are completely opake like paste or cheese, exactly resemble the
oldest fibrinous layers of false aneurisms, and adhere so firmly to the
walls of the heart, that they cannot be detached without scraping with
the scalpel, and sometimes without removing the internal membrane.
Causes and formatim of Polypous Concretions.— -Two opinions have
been entertained respecting the formation of polypi: 1. Some have
attributed them to retardation of the blood, an entirely physical cause.
2. Others have ascribed them to inflammation; that is, in other words,
to causes acting chemically or vitally on the blood. Modern expe-
rience shows that both of these opinions are correct.
1. When polypi result from mechanical retardation and consequent
stagnation of the blood, we find them to occur under circumstances
the most favourable to that stagnation: namely, during the last hours
or days of waning life in all diseases — especially chronic diseases
which have occasioned cachexy, emaciation, extreme debility, or
which have been accompanied by any considerable obstacle to the
general circulation ; for instance, dilatation with attenuation, softening,
or great valvular disease of the heart. Under these circumstances,
so re'arded is the circulation that blood will scarcely flow from the
veins, opened by the lancet, and it sometimes actually coagulates in
them. I have taken notes of a number of cases of phthisis, in which
this coagulation took place in the femoral veins, and caused oedema
of one or both extremities. That stagnation alone suffices to cause
coagulation, is a fact too familiarly known to require demonstration.
We see it, out of the body, in blood drawn by the lancet: we see it
exemplified within the body, by the fibrinous concretions that fill up
false aneurisms; the operation for this disease, moreover, has for its
basis the coagulation in question.
The adhesion of polypi from stagnation appears to be occasioned
by the irritating action of the body itself on the walls of the heart;
whence there results an exudation of lymph on the latter, which
forms the agglutinating medium. I once saw this process strikingly
exemplified in the veins. Loose coagula were found in most parts
of the venous system; but, in the vena portae, they were adherent
wherever larger trunks, subdividing into others too small to admit
them, had arrested their progress.
2. The knowledge of the chemical or vital causes of coagulation
of the blood is one of the improvements of modern medical science.
It is well ascertained, that when the walls of a vein or artery are in-
flamed at any particular spot, the first effect of that inflammation is
to cause coagulation of the blood within the vessel at the inflamed
part; and here it is to be presumed that the inflammation exercises
deny that particles of pus may be the nuclei of coagula within the heart; for I
have seen such coagula, some suppurating and others not, floating loose in al-
most every considerable venous trunk through the system of the same patient.
(See the writer's Morbid Anat. Fig. and case 110. >
32*
486 HOPE ON DISEASES OF THE HEART.
some vital influence over the constitution of the blood within its
reach, disposing it to coagulate. If this can take place within the
bloqd-vessels, it is consistent to suppose that it may occur equally
within the heart, when the interior of the organ is inflamed; accord-
ingly, the cases of fatal acute endocarditis which M. Bouillaud has
met with, and in which he has found polypi evidently formed some
time before death, afford strong evidence that such is actually the
case. This writer, moreover, is of opinion that a general inflamma-
tory condition of the blood, dependent on "any pure inflammation
in which there is violent fever, and where the blood drawn from a
vein presents a good, fivm, elastic, resistant buffy crust, constitutes a
real predisposition to certain fibrinous concretions of the heart, which
have then a great resemblance to the inflammatory buff," Thus, on
referring to the cases in his work, "it will be seen," says he, "that
in most of the instances in which the fibrinous concretions did not
proceed from a mere embarrassment of the circulation, they accom-
panied, either an idiopathic inflammation of the heart, or an inflam-
mation of another organ, which reacted smartly on the heart, as well
as on the whole circulatory system and mass of blood " (Traite, ii.
p. 612). This doctrine is far from improbable; yet it will, I think,
require for its establishment a greater number of cases than are re-
corded in the work of M. Bouillaud; for we must not come too has-
tily to the conclusion in question, when we consider how frequent
are acute inflammations, and how comparatively rare is their termi-
nation in polypus.
Another well-known cause of coagulation of the blood by a vital
.oi* chemical influence, is pus introduced into the circulation, whence
proceed visceral abscesses, typhoid symptoms, &.c. Experiment has
shown that the same effect is produced by the introduction of vari-
ous foreign substances into the blood, as mercury, acids, &c.
Signs and Diagnosis of Polypi of the Heart. — 1 stated above that
symptoms which are now known to depend on organic disease of the
heart, were formerly attributed solely to polypi ; this error arose
from physicians not being sufficiently acquainted with morbid ana-
tomy to recognise organic disease of the heart in those individuals
in whom, after the existence of the symptoms in question, they dis-
covered polypi.
The effect of polypi is, to cause a greater or less obstacle to the
circulation according to their size and situation. I have generally
found those filling up an auricle produce this effect in a greater de-
gree than any others, probably because the auricle, from having less
contractile power to expel the stagnating blood, gets more complete-
ly charged with the concretions, and partly also because auricular
polypi usually send off prolongations or projections into the orifices,
which not only impede the action of the valves, but also choke up
the passage. When polypi form suddenly a short time previous to
death, as within a week or ten days, they exceedingly aggravate all
the symptoms of an impeded circulation; and this they do, both in
diseases in general, and more especially in diseases of the heart.
POLYPUS — PHYSICAL AND GENERAL SIGNS. 487
When, in the latter, they nearly obliterate the cavities or orifices of
the heart, they prove rapidly fatal.
Physical Signs. — M. Laennec thinks that polypi of considerable
magnitude may be recognised by the following physical signs.
" When, in a patient who, till then, had presented regular pulsations
of the heart, these suddenly become so anomalous, confused, and ob-
scure, that they can no longer be analysed, we may suspect the for-
mation of a polypous concretion ". (De PAuscult. torn. ii. p. 597).
The obscurity of the sounds proceeds from the play of the valves
being impeded. I have not found any murmur attend the sounds, but
others have, in a few rare instances; and I conceive it possible, if
the polypus should happen to entangle a valve while the current
through the auricles and ventricles remains tolerably free. Before,
however, the murmur can be assumed as a sign of polypus in a given
case, it must be proved 1. that it did not previously exist, and 2.
that it is not a result of valvular tumefaction from acute endocardi-
tis. Whether the murmur be musical or not, is unimportant.
But though the irregularity described by Laennec be a sign of
polypus in cases where the action of the heart wTas previously regu-
lar, it has not the same value in cases where this previous regularity
did not exist, and such cases form a large proportion of the instances
in which polypus occurs. If, however, even in the latter cases, the
irregularity be suddenly aggravated — become unusually "anomalous,
confused and obscure;" and if, together with this aggravation, the
general signs be taken into consideration, the diagnosis may, I pre-
sume to think, be almost always formed with accuracy.
General Signs. — The general signs, according to my observation,
(for they were wholly unnoticed by Laennec, and scarcely glanced
at by Bertin and Bouillaud), are, a sudden and excessive aggravation
of the dyspnoea, without any other obvious adequate cause; the pulse
is small, weak, irregular, intermittent, and unequal; the patient is in
an agony from an intolerable sense of suffocation; he cannot lie for a
moment, and he continues tossing about in the most restless and dis-
tressed condition until his sufferings are terminated by death. During
this state the surface and extremities are cold, the complexion livid,
and, in most cases, there is nausea, and vomiting of all ingesta. To
this category, M. Bouillaud has added stupor and slight convulsive
movements, which supervened in one of his cases. It has been ex-
plained at p. 215, that these same signs occur when there is an extreme
obstruction to the circulation through the heart, whatever be its
cause.
Polypi, formed a considerable period previous to death, are not so
easily detected, their deposition being more gradual. Still, if symp-
toms of the above kind, both physical and general, come on more
rapidly than can be accounted for by the ordinary progress of the
disease, or if they are such as the disease could not be supposed
capable of producing, there is strong reason to suspect a polypus.
The small globular polypi often exist without producing any obsta-
cle to the circulation, or any irregularity of the action of the heart.
488 HOPE ON DISEASES OF THE HEART.
In general, however, they are found in those who have been in a
moribund state for many days and sometimes many weeks before
death.
Treatment of Polypus. — The treatment is mainly preventive; since,
when the concretion is once formed, the case is almost hopeless. One
of the greatest dangers of excessive blood-letting or otherwise reducing
the system, and of the indiscreet exhibition of nauseants and digitalis,
in advanced stages of organic disease of the heart, arises from the risk
of the formation of polypi in consequence of languor of the circula-
tion. I am satisfied that this circumstance is not in general sufficiently
attended to, even up to the present time.1
The best mode, according to my observation, of obviating polypus
in advanced cases of organic disease of the heart, is, to keep the pa-
tient in a state of the utmost possible tranquillity, and in the easiest
attainable position, so that the circulation may not become embar-
rassed from being hurried; to avoid not only nauseants and digitalis,
but any other unpalatable remedies which disgust or derange the sto-
mach; to avoid, for the same reason, any but the most simple and
digestible articles of diet, and not to introduce much into the stomach
at once; for the action of the heart invariably becomes disturbed
whenever the stomach is considerably distended either by food or,
what is almost as bad, by flatulence, the effect of both being to pre-
vent the descent of the diaphragm, in addition to their influence
through the medium of the nervous system. Though the adminis-
tration of aqueous drinks, with the view of diminishing the coagula-
bility of the blood by dilution, is plausible in theory, I have generally
found it inadmissible in practice beyond a moderate extent, in conse-
i I cannot but protest against the indiscriminate, I had almost said random,
manner in which M. Bouillaud advocates blood-letting for the prevention of
polypus. Without specifying any of the circumstances which should guide its
employment, he says in round terms, " To prevent the formation of concretions
of blood in diseases of the heart, whose property it is to impede the current of
the blood, it is useful to employ blood-letting from time to time, and to dilute
the blood in a manner by aqueous beverages." Now, I have seen enough of
blood-letting in this country, (where practitioners have never been very shy of
its employment as an empirical mode of relieving severe attacks of dyspnoea
from whatever cause), to know that, in dilatation of the heart, in softening, and
in advanced cases of valvular disease, blood-letting will not only fail to prevent
polypi, but -will actually induce them, as stated in the text, and moreover will
favour the supervention of dropsy, exhaust the vital powers, and hurry the case
to its fatal termination. Moderate blood-letting may, indeed, be admissible, in
the early stages of hypertrophy, even when complicated with valvular disease,
but these are not the cases in which polypus is apt to occur.
Again, "blood-letting," adds M. Bouillaud, " is likewise the best means that
can be employed against concretions of the heart already formed. It has suc-
ceeded beyond my hopes in a female admitted under my care (Ward St. Mag-
dalen, No. 3), the 7th of this month. (May 1835.) A prey to the most immi-
nent suffocation, and offering, moreover, the physical signs of polypus, such as
I have explained them above, she has been bled three times, and is at this mo-
ment (May 25th) in a satisfactory state." (Traite, ii. p. 618.) Thus, without
offering more authority than a single case, and that still in the wards, he offers
an unqualified recommendation of blood-letting! Surely this is hasty generate
zation,
POLYPUS — TREATMENT. 489
quence of the intolerable flatulence which it is apt to generate. Nor
must it be forgotten that nature often contradicts the very principle
itself; for, while the practitioner is diluting 'the blood, she is often
doing her utmost to get rid of that dilution in the form of dropsy;
and that her measures are often the wisest, no one will deny who has
observed the great relief to the vascular and respiratory system, which
frequently follows a considerable serous infiltration. There can be
no doubt, indeed, that dropsy, under these circumstances, is a curative
effort of nature.
Such are the negative means of obviating polypus; but there are
others of a positive nature, to which the practitioner may resort with
advantage. The general surface and especially the extremities should
be kept comfortably warm, so as, by diffusing the circulation, to pre-
vent congestion in the heart and great vessels. At the same time,
cool, fresh air may be admitted to the head, as this often wonderfully
alleviates the craving for breath and consequent restlessness of the
patient. On the same principle, the use of the fan is most agreeable.
Of medicines, I have found those containing sp. aeth. sulph. comp.
and ammoniae sesquicarbonas the most generally useful — probably be-
cause, as diffusible stimulants, they distribute and equalize the cir-
culation. In circumstances of great debility, the addition of more
permanent stimulants, wine or brandy, becomes indispensable. When
paroxysms of congestion of the heart come on, indicated by unusually
confused, irregular action of the organ, with an exceedingly small,
weak, irregular pulse and suffocative dyspnoea, no remedy affords so
much relief as a foot-bath up to the knees, at as high a temperature
as the patient can bear it. If he cannot move, the same may be
accomplished with much less fatigue by wringing a small blanket out
of hot water and surrounding his legs with it up to the knees, dis-
comfort being prevented by enveloping the whole in india-rubber
cloth. This may be repeated two, three, or even four times a day,
if urgently required, the legs, in the intervals, being kept warm with
flannel.
M. Legroux has suggested the use of the preparations of soda and
potass, as having a solvent effect on the blood. They certainly ren-
der the blood florid out of the body, and the experience of Dr. Ste-
phens in yellow, and other typhoid fevers, and of many in this
country in malignant cholera, render it highly probable that they
have some corresponding, or at least salutary, effect on the blood
within the vessels. Dr. Stephens gives a combination of the carbo-
nates of potass and soda and the chlorate of potass. Further obser-
vation is necessary to prove whether these remedies are calculated to
obviate polypus.
Such is the treatment when the case is not connected with inflam-
mation: when it is, the inflammation itself must be treated; and if
the measures which have been already recommended for pericarditis
and endocarditis be adopted, I believe, according to my own obser-
vation, that polypus will be of very rare occurrence,
490 HOPE ON DISEASES OF THE HEART.
Can polypi, once formed, be dissolved? M. Bouillaud answers
this question in the affirmative. «< It appears to me indubitable,"
says-he, " that concretions of recent formation and small volume are
susceptible of this mode of termination" (Traite, ii. p. 618): but it
may fairly be asked whether it is possible indubitably to ascertain
the existence of a concretion of "small volume." Organized and
adherent polypi are, of course, unsusceptible of solution.
CHAPTER II.
DISPLACEMENTS OF THE HEART.
The heart being sustained in its place principally by the equal
pressure of the lungs on all sides, may be displaced when that pres-
sure is rendered unequal. I have seen this occur from pneumotho-
rax, by which the organ was forced completely to the right of the
sternum; by the same affection with hydrothorax producing a simi-
lar effect; by hydrothorax alone (case of Rowe and Mitchell;) by in-
flammatory pleuritic effusion, both acute and chronic; by aneurism
of the ascending aorta, displacing it to the left (case of Hill); by ex-
treme enlargement of the liver; [by ascites]; and by enormous fun-
gus hsematodes of the right lung. It may also be displaced by em-
physema of the lungs, being pushed to the opposite side when a
single lung is emphysematous, and into the epigastrium when both
are affected: also, by tumors in the anterior mediastinum, and by
aneurisms of the arch of the aorta. The two latter causes generally
force it downwards. When the heart is enlarged, it is displaced by
its own gravitation to a lower situation than natural.
I at present attend a young lady, Miss M., in whom the heart
was forced entirely over to the right of the sternum by pleuritic ef-
fusion in the left pleura. The aorta was felt to pulsate between the
second and third right ribs, an inch from the sternum, and. here a
murmur was heard with the first sound, which has ceased since the
heart has been restored to its natural situation by the absorption of
the fluid. Is it therefore possible that a twist given to the aorta, or
pressure of the vessel against the ribs, may be the cause of a murmur
under such circumstances?
I have at present two cases of still greater displacement of the
heart to the right, in consequence of universal consolidation and con-
traction of the right lung, and hypertrophy of the left. The as-
cending aorta beats between the second and third right ribs, two and
a half inches from the sternum, in one case, (a man aet. 40,) and one
and a half to two, in the other (Phosbe James, see p. 134). There
is a murmur with the second sound, from aortic regurgitation^ in the
former case. It remains to be seen whether regurgitation proceeds
HYDROPERICARDIUM. 491
from a twist in the aorta, disabling the valves, or from disease of
the valves themselves. The pulsation of the aorta so far on the
right, might be, and actually was, mistaken by non-auscultators for
an aneurism.
When the heart is displaced to the right just so far as to be im-
pacted between the sternum and the spine, I have found its impulse
to be considerably increased, so as to convey the idea of hypertrophy.
This occurred in the case of Miss M. above described, and, until I
pointed out the circumstance, the disease was mistaken for hypertro-
phy, the pleuritic effusion being overlooked. The phenomenon re-
sults from the spine presenting an unyielding fulcrum behind. I
have already shown that the same occurs in adhesion of the pericar-
dium (p. 199), and in cases of solid tumors, as aneurisms, immedi-
ately behind the heart p. 424.) Dr. Stokes has also observed it in
cases of tubercular consolidation of the lung behind the heart.
Symptoms. — Slight displacements occasion little inconvenience:
when considerable, they may create serious functional derangement,
especially palpitation.
Diagnosis. — Displacements are easily detected by auscultation and
percussion. The situation of the apex may generally be discovered
by its impulse and the usual dulness on percussion: that of the
semilunar valves may be detected by tracing the second sound to
the point where it is loudest. When the ascending aorta is dis-
placed from beneath the sternum, as in the above three cases, its im-
pulse may be felt between the second and third ribs.
CHAPTER 111.
HYDROPERICARDIUM.
Serous effusion in the pericardium is common as an attendant of
general dropsy, but very rare as an idiopathic disease. I doubt, in-
deed, whether there is such a disease as acute hydropericardium in-
dependent of inflammation. I never met with a case, nor have I been
able to find unequivocal instances recorded by authors, the bulk of
those reported as such evidently being nothing more than serous ef-
fusion from pericarditis. When the fluid does not exceed three or
four ounces in cases in which the hydropic diathesis prevails, it may
be merely an exudation which lias taken place during the last period
of life; and when it does not exceed one or two ounces in ordinary
cases, it may be ascribed to the same cause.
In general dropsy, the pericardium usually contains less fluid, in
proportion, than other serous cavities. I have never seen the quan-
tity amount to a pint: Corvisart states that he has once seen it
amount to eight; but I suspect that this was a case of chronic peri-
492 HOPE ON DISEASES OP THE HEART.
carditis. The fluid is sometimes colourless, but usually it is yellow-
ish or brownish, though transparent and free from albuminous flakes;
occasionally, though very rarely, it is bloody.
Signs and Diagnosis. — The signs of hydropericardium given by
authors are obscure. The weight in the region of the heart, the sen-
sation of the organ floating, experienced by the patient, undulations
as of fluid, felt and even seen in the intervals between the third,
fourth, and fifth ribs, irregular action of the heart, a small, frequent
and intermittent pulse, orthopncea, palpitation, and syncope, are signs
common to other complaints, and therefore unworthy of confidence,
except as corroborating others more characteristic.
Laennec expresses himself unable to say what signs auscultation
will supply, but thinks that effusions less than a pint will not afford
any: and that we shall probably never be able to detect hydroperi-
cardium which is not even much more considerable. After much
attention to this subject, I think it is in general possible to detect
from eight or ten ounces upwards1 by the following signs.
Dulness on percussion is preternaturally extensive, and I have
known it mount under the sternum, in a conical form, as high as the
second rib; the motions of the heart as perceptible beyond the ordi-
nary limits; the impulse is of an undulatory nature, some beats being
stronger than others, and the point at which they are most sensible,
varying every moment; the impulse does not accurately coincide
with the sound of the ventricular contraction, as the heart has to re-
move the interposed fluid before it can impinge against the thoracic
walls; the first sound is dull and remote, in consequence of the in-
tervention of the fluid; finally, the sensation communicated to the
hand and the stethoscope is that of an impulse transmitted through a
fluid, and not of an organ striking the ribs immediately. When the
quantity of fluid is very great and the action of the heart feeble, the
impulse, I have found in several instances, may be totally impercep-
tible: in which case the signs are, the unusually extensive, conical
dulness — greater than can be accounted for by hypertrophy, and the
dulness and remoteness of the first sound opposite to the apex of the
heart.
Hydropericardium from general dropsy requires the same treat-
ment as the dropsy. For reputed idiopathic hydropericardium,
(which, as above stated, is apparently nothing more than chronic pe-
ricarditis), tapping has been suggested by Senac, countenanced by
Laennec, and practised, but unsuccessfully, by Desault and others.
Laennec thinks that the least dangerous mode of operation would
be, that of trepanning the sternum above the xiphoid cartilage, as,
thus, the pleura would not be opened, and the diagnosis might be ve-
rified by inspection before the pericardium was punctured. To my-
self the operation appears inadmissible; for, independent of its dan-
ger, unless adhesion were effected by exciting "pericarditis, the fluid
would probably be regenerated, as in hydrocele and ascites.
1 In the cases of Bryant and Snowden a much less quantity was detected,
but 1 would not venture to say that so little could always be recognised.
PNEUMOPERICARDIUM. 493
CHAPTER IV.
PNEUMOPERICARDIUM.
Laennec assigns this name to effusions of air within the pericardi-
um, which are very frequently found on dissection. In subjects that
have been kept for some time, the effusion is to be ascribed to de-
composition; but in many others, judging from the absence of all
signs of putrefaction, it is anterior to death. Most frequently, it is
conjoined with a liquid effusion, and the two may take place simul-
taneously in the last moments of life in any disease. Laennec
states that he has sometimes detected it by an unusually clear reso-
nance at the base of the sternum which had supervened within a few
days, or by a sound of fluctuation attending the beats of the heart
and strong inspirations. Though he has not had an opportunity of
verifying the fact, he is convinced that, in almost all cases in which
the beats of the heart can be heard at a certain distance from the
chest, this phenomenon is due to the temporary effusion of a gas,
which is in general promptly absorbed, and the presence of which
in the pericardium creates no serious inconvenience (De l'Auscult.
torn. ii. p. 672 and 455). This is very questionable. I have never,
indeed, been able to verify any of the above remarks. Wind and
fluid in the stomach might deceive a less cautious observer than
Laennec.
Air is sometimes found on dissection in the cavities of the heart.
Dr. Forbes of Chichester favoured me, in 1830, with the following
communication: " I yesterday examined a boy who had died sudden-
ly, after being affected for years with all the symptoms of extreme
dilatation of the heart. I found the organ very large from dilatation
of both ventricles, and both were distended with air — in all eight or
ten ounces. There was no particular putridity, the boy having been
dead only thirty-six hours." A similar case is recorded in Sim-
mons's London Medical Journal, part iii. for 1785. As air in the
ventricles is incompatible with the maintenance of life, it must, in
these cases, have been generated, or conveyed there, after death; but
if putrefaction be its cause, it is remarkable that the phenomenon is
so rare.
12— f 33 hope
PART VI.
CASES.
The following cases, together with those scattered throughout
the work, though few in number, present well-characterized exem-
plifications of nearly all the ordinary, as well as the more rare dis-
eases of the heart: also of the general histories and signs given in
the antecedent parts of the work. I have, for the sake of brevity,
omitted the physical signs of pulmonary affections, but have in ge-
neral adverted to the affections in the diagnosis, and succinctly de-
scribed them in the post-mortem examinations. I have likewise
omitted details of treatment; for, though pre-eminently important
to the observer, they afford comparatively little instruction to the
mere reader, by whom, in consequence, they are seldom perused.
Having found it impossible perfectly to classify the cases under
the heads of hypertrophy, dilatation, valvular disease, &c, in con-
sequence of these affections being in general complicated with each
other, I have merely thrown the several classes rudely together, as
far as practicable, and have given an alphabetical index to the names
of the patients, which will afford every facility of reference.1 A
few of the less complete cases of the former editions I have struck
out of the present, and substituted others of an interesting nature,
and illustrating particular points, for the most part new.
Great Hypertrophy with Dilatation; Hydropericardium; Emphyse-
ma; Peripneumony. — Robert Bryant, set. forty-two, of sallow and
livid complexion, was admitted into St. George's Hospital under
Dr. Chambers, May 6, 1829, with cedema of the lower extremities,
cough, dyspnoea and palpitation increased on exertion, starting from
sleep, great pulsation of the jugular veins, especially the right, pulse
100, full and strong, urine free but thick.
Had dropsy thirteen years ago. The present symptoms came on
three months ago. commencing with cough. Was previously in good
general health, and did not complain of shortness of breath.
1 It may be stated, in reference to the cases taken in St. George's Hospital
anterior to 1831, that minutes of the physical signs of disease of the heart
were written by other gentlemen in the hospital, as well as myself: more espe-
cially by Mr. Johnson, then house-surgeon to the institution; — a gentleman no
less remarkable for an intimate knowledge of auscultation, than for general talent
combined with a sound judgment and a liberal mind. -I have pleasure in stating,
in corroboration of the accuracy of my own minutes, that those of Mr. Johnson
coincided with them closely and often verbally, though we had no communi-
cation until both were written.
cases. 495
The resonance of the precordial region is dull over an expanse of
five inches in diameter. The impulse of the left ventricle is strong,
extensive and undulating, with a violent receding jerk or shock when
the heart retires. The first sound of the left ventricle is scarcely
audible, but the second sound is sufficiently smart and loud.
Diagnosis. — Hypertrophy and dilatation of the heart. Hydroperi-
cardium. Little if any hydro thorax. Lungs gorged and emphysema-
tous.— R Pil. Hydr. gr. v. Scillae pulv. gr. i. Pil. bis die s. R Haust.
nitri, Sp. seth. nitric. — Junip. C. aa 31 m. ft. haust tcr die. R Haust.
sennge, Tr. Jalapae gi m. ft. haust o. m. Diocta lactea.
Five days after admission he was attacked with peripneumony,
for which gxii of blood were drawn, and ^x four days afterward.
Sputa viscous and rust-coloured, pulse became irregular, sleep dis-
turbed. (Cont. Med.) Was relieved for two or three days, when
he had a violent attack of palpitation and orthopnea. Pulse 110,
sputa bloody, mucous rales in the throat and lungs (V. S. anodynes
and diaphoretics). The paroxysm subsided in 3G hours, but he gra-
dually sank, and died on the 23d.
Autopsy — Left ventricle immensely hypertrophous; right, consi-
derably: both dilated: valves sound: ^iv of serum in the pericar-
dium: gij in the cavities of the chest. Lungs. Hepatization of the
inferior lobes on both sides. It is sero-purulent. of chocolate colour,
and very flaccid and lacerable. Parts of the middle lobes are in the
first degree of peripneumony. The remainder of both lungs is bloated
with emphysema and oedema.
Remarks. — The hypertrophy occasioned the power of the impulse,
the dulness of the first sound, and the strength of the pulse; while
the dilatation rendered the second sound sufficiently loud and smart,
the pulse full, and the impulse and praecordial non-resonance more
extensive than in hypertrophy alone. The great predominance of the
hypertrophy over the dilatation prevented the latter from increasing
the first sound. The violence of the back-stroke resulted from the
hypertrophy and dilatation conjointly; as the augmented power and
weight of the heart, and the increased influx of blood during the ven-
tricular diastole conspired to render that motion boisterous. The
fluid in the pericardium increased the extent of dulness on percussion,
and imparted the undulating character to the impulse. The latter is
in consequence of the fluid being displaced by the motions of the
organ; and as these motions are more violent in cases of hypertrophy,
the undulation is proportionally greater. So small a quantity as |iv
cannot in general be detected with certainty. The pulse, at first re-
gular, as is generally the case in uncomplicated hypertrophy, became
irregular in consequence of the engorgement of the heart occasioned
by the pulmonary obstruction and the reduction of the vital powers.
As it is almost certain that the hypertrophy existed to a greater or
less degree, at the time of his former dropsical attack thirteen years
before, and as he had remained during the interval without complainr
ing of bad health, the case tends to show that hypertrophy, in its sim-
ple state, may exist for a series of years without creating so much in-
convenience as to incapacitate a working man.
496 HOPE ON DISEASES OF THE HEART.
Emphysema is one of the most dangerous complications of peri-
pneqmony; for, as the dyspnoea which it occasions is liable to be attri-
buted solely to the inflammation, blood-letting may be carried to
excess; and thus, the vital powers being diminished while the obstruc-
tion in the lungs remains, the patient sinks suddenly and unexpectedly.
Several cases of this description have fallen under my observation.
The present is not of that number, as the emphysema was detected
by Dr. Chambers, and the depletion judiciously regulated accordingly.
Enormous dilatation with hypertrophy of both ventricles; enlarged
liver; fits from cerebral congestion; anaimic pulsation, tremor, and mur-
mur of the carotids and subclavians. — Richard Collard, aet. 36, a coach-
maker, of large frame, but emaciated and affected with jaundice, was
admitted in St. George's Hospital, under Dr. Chambers, August 19th,
1S29, with ascites; great oedema of the legs; dyspnoea, exasperated
by every movement; cough; great pulsation of the carotids; varicose
intumescence and undulation of the jugulars; impulse of the heart
preternaturally strong and extensive; pulse bounding but not hard,
moderately full and rather vibrating; skin clammy; tongue whitish;
bowels open; evacuations of a light clay colour; urine scanty and
deep-coloured. Liver is felt to be enlarged.
Has been more or less ill for two years. Complaint is attributed
to fretting. It commenced with shortness of breath and loss of ap-
petite. Dropsy first appeared six months ago, and skin became yel-
low five or six weeks ago. Is said to be subject to fits.
Auscultation. — Resonance very dull over the whole of the prsecor-
dial region. Impulse is a powerful heaving, terminating in a jerk or
back-stroke: it is felt much more extensively than natural, and in the
epigastrium. Both sounds are louder, and the first a little more brief,
than natural. Above the clavicles there is a slight impulse with very
feeble purring tremor and a whizzing sound, not loud or hoarse.
Diagnosis. — Great hypertrophy with dilatation of the heart; enlarge-
ment of the liver. — R ung. hydr. fort. 31 hepatis regioni mo. noct. in-
fricand — Haust. nitri, sp. seth. nitrici ^i m. f*. haust. ter die — Potassse
supertart. gss, jalapse pulv. gr x, om. noct. sumend.
During the first week he had three fits, which consisted of stupor,
with slight convulsions and stertor, succeeded by sleep. The last
attack was of two hours' duration. The dropsy was greatly reduced
by the remedies; but he sank exhausted on the eighteenth day after
admission.
Autopsy. — Heart double its natural size, and, as he was of large
frame, it was enormous. Left ventricle would contain a full-sized
lemon, and the parietes were three-fourths of an inch thick. Right
ventricle was similarly affected, but' in a rather less degree. The
muscular substance was pale and somewhat softened ; it presented a
mottled appearance. Valves and aorta natural." Hydrothorax to four
pints. Lungs gorged with serum. Mucous membrane of the bronchi
vascular, and of a dim red colour. Liver twice its natural size, of in-
tense yellow (ochre) colour, and its acini were enlarged in every de-
gree up to the size of a pea. Brain healthy, but fluid under the
arachnoid membrane.
cases. 497
Remarks. — The extraordinary degree of hypertrophy with dilata-
tion was distinctly marked by the extensive dulness of the precordial
region on percussion, without signs of hydropericardium; by the
powerful heaving and back-stroke; and by the loudness of both
sounds. The predominance of the dilatation over the hypertrophy,
prevented the pulse from being so hard and incompressible as the
hypertrophy would otherwise have rendered it. Pulsation, vibra-
tion and whizzing sound of the larger arteries, as in the present case,
are common in anaemia, and still more when an increased quantity of
the attenuated blood is transmitted through the vessels with aug-
mented force. They may easily be distinguished from the same re-
sulting from aortic dilatation or disease, by the superior hoarseness
of the sound and vigour of the impulse in the latter affections. The
disease of the liver was most likely a result of congestion occasioned
by impeded circulation of blood through the heart and lungs. The
varicose and tumid state of the jugular veins depended on the same
cause, while their pulsation was due to the hypertrophy of the right
ventricle. The fits were dependent on the violent determination of
blood to the brain. I have in many instances known such attacks
recur repeatedly, and at last terminate in a fatal apoplectic seizure, —
a common result of hypertrophy of the left ventricle. Individuals
reduced by years or disease, often sink suddenly, as in the present
instance, after the disappearance of much dropsical infiltration. The
older physicians supposed that this was in consequence of accumula-
tions in the great cavities; but as, in a large proportion of cases, dis-
section disproves the existence of such accumulations, dissolution
must be ascribed to a failure of the vital powers.
Hypertrophy of Ike left ventricle, disguised by emphysema; dilatation
of both; disease of the interior of the aorta; angina; emphysema and
adema of the lungs. — David Keith, aet. 70, emaciated, of middle stature,
and sallow complexion, with a circumscribed redness of the cheeks,
was received into St. George's Hospital, September 2d, 1829, sub-
ject to severe pain at the inferior part of the sternum and across the
epigastrium, which comes on about midnight, accompanied with or-
thopnea amounting almost to suffocation. The paroxysm lasts seve-
ral hours. Cough; dyspnoea on motion; cannot expand either side of
the chest; its resonance is good, and in some parts (namely, the an-
terior and superior) it is more sonorous than natural; pulse 116, large
and strong; bowels regular; flatulence.
Says that the asthmatic fits commenced only two months ago; and
he attributes them to a "violent cough" which had existed for two
months previously. Anterior to that time he did not suffer from
dyspnoea. Has taken aperients and been bled.
Auscultation when the circulation was tranquil. Impulse of the
heart not considerable. Both sounds are short and flat, and so loud
as to be distinctly audible above the right clavicle. They are ob-
scured below by the catarrhal rales.
Diagnosis. — Dilatation of the heart. Emphysema of the lungs; oedema
of the lower lobes; chronic bronchial catarrh.
33*
498 HOPE ON DISEASES OF THE HEART.
R sp. aeih. sulph. gss, mist, camph. 3x, bis die — R Hydr. submu
gr. ij, Pulv. Jacobi et Pil. sapon. cum opio aa gr. v. fiant pilulse iij
omni nocte sumendte.
The asthmatic attacks were diminished for a week, but they re-
curred with aggravated violence in consequence of his taking fresh
cold. October 13th, cough worse, with inability to expectorate from
weakness; dyspnoea, emaciation and paleness are increased; voice a
whisper; pulse 98, rather unequal; tongue dry; thirst; anorexia; loud
sonorous rales over the whole anterior chest. These symptoms in-
creased, and he expired on the 28th October.
Autopsy. — Left ventricle was an inch thick, and dilated to about
one-half larger than natural. Muscular fibre red and firm. Right
ventricle dilated to the same extent, but not thickened. Margins of
the valves in parts slightly thickened with fibro-cartilage, but not
sufficiently to cause symptoms. Aorta, to the extent of an inch and
a half above the valves, very slightly dilated, and, opposite to the
origin of the left subclavian, somewhat contracted. Its interior uni-
versally overspread with firm, cheese-like matter, intermixed with a
few calcareous scales. This state extended to the pelvic bifurcation.
Lungs. — Extremely large, and did not collapse when the chest
was opened, in consequence of being universally distended by em-
physema and oedema. Air vesicles enlarged — some to the size of
pins' heads, and their insufflated state rendered many of the superfi-
cial lobules prominent and perfectly pale. Spumous serum exuded
copiously on pressure. The lower lobes were in the state of choco-
late-coloured flaccid engorgement, heavier than water, but not puru-
lent or lacerable. Some of the great bronchi were of an indelible
brownish red colour, and contained purulent mucus.
Remarks. — One of the most instructive features of the present case
was, that interposition of the bloated lungs between the heart and the
thoracic parietes prevented the resonance of the praecordial region
from being so dull, and the impulse of the organ from being so strong,
as such a degree of hypertrophy and dilatation would otherwise have
rendered them. The action of the heart was not proportionate in vio-
lence to the extent of the enlargement, owing, perhaps, to the ad-
vanced age and great emaciation and exhaustion of the patient. The
existence of murmur from the ruggedness of the aorta could not be
ascertained, in consequence of the loudness of the pulmonary rales.
In this, as in many similar cases, the disease of the heart was called
into fatal activity by the superadded impediment to the circulation
from emphysema and oedema, &c. of the lungs. The supervention
of the asthmatic fit during the night was favoured by the recumbent
position, and by the accumulation of mucus during sleep. The pain
in the region of the heart, commonly called angina pectoris, must be
referred to nervous irritation occasioned by the gorged and labouring
state of the organ.
Hypertrophy and dilatation from pericarditis ; peripneumony. — John
Green, aet. 43, a groom, of middle stature and pale, fair complexion,
was received into St. George's Hospital under Dr. Chambers, January
cases. 499
6th, 1830, with "a weight in the chest;" dyspnoea and palpitation in-
creased by any exertion; cough; viscid, rust-coloured sputa, some-
times black with grumous blood; hoarseness; orthopnoea; pulse 120
sharp; tongue thickly furred and yellow in the centre, pale at the
edges; thirst; anorexia; bowels costive; urine scanty and offensive;
emaciation.
Had been suddenly attacked, three months before, with dyspnoea,
palpitation and the other symptoms (pericarditis). They had been
occasionally relieved, but, on his admission, were worse than ever.
Previous to the attack, he was healthy.
Auscultation. — Increased sound and impulse of the heart.
Diagnosis. — Peripnenmony ; enlargement of the heart.
V. S. ad 3xij. R Haust. salin. cum oxym. scillae ^ss, 6tis horis. R
Hydr. submu. gr. v. hac nocte, et haust. sennae eras mane. Diaeta par-
ciss. The blood was highly buffed; and as the symptoms continued
and the pulse had become 84 and full, venesection was repeated to the
same extent, and took calomel gr. ij. with opium half a grain, 6ti8
horis. These and all the other means employed were incapable of
affording relief, and he expired on the sixth day.
Autopsy. — About ^xij of serum in the cavities of the pleura; old
adhesions on the left side; lungs more voluminous than natural from
emphysema and oedema; the inferior portions of both were hepatized;
namely, of reddish chocolate colour, heavier than water, flaccid,
lacerable, and in some parts purulent. Where the latter character
exists, the colour is paler and the ramollisscment greater.
Pericardium partially overspread with organized lymph, but not
adherent. Left ventricle three-fourths of an inch thick at the base
and one half at the apex; its cavity dilated to twice its natural capacity.
Right ventricle equally dilated, but not hypertrophous. Lining mem-
brane on both sides was stained of deep crimson colour. Muscular
substance was pale and flaccid, but not lacerable. Valves natural; a
slight steatomatous deposition around the coronary arteries.
Remarks. — The lymph on the pericardium, the paleness and flaccid-
ity of the muscular substance, the intense redness of the lining mem-
brane, and the sudden supervention of all the symptoms three months
previous to admission, afford almost positive proof that the affection
was originally pericarditis or endopericarditis, the softening occasioned
by which had led to the great and rapid dilatation. The increased
action and sound of the heart, and the state of the pulse, denoted the
enlargement of the organ. The supervention of peripneumony while
the heart was still labouring under the effects of inflammation, ren-
dered the case extremely formidable, if not altogether hopeless.
Enormous hypertrophy and dilatation of the heart; disease of the aortic
valves with regurgitation and jerking pulse; universal adhesion of the peri-
cardium; acute rheumatism; anaemia. — John Copas, set. 24, a gardener,
of middle stature and robust frame, cadaverously pale, was admitted
into St. George's Hospital under I)r. Chambers, October 14, 1829,
with universal rheumatic pains, aggravated when Warm and per-
spiring; very slight oedema of the legs; face rather puffy; palpitation;
500 HOPE ON DISEASES OF THE HEART.
sleep disturbed by starting; the pulsation of the heart not only per-
ceptible to the touch, but visible over nearly the whole anterior sur-
face of the chest, and particularly in the epigastrium. Resonance of
the precordial region extremely dull; pulse 120, full, strong and
regular, but compressible — a circumstance particularly pointed out to
me by Dr. Chambers.
He had suffered from acute rheumatism eight years before, and had
never since been exempt from palpitation.
Auscultation was not employed.
Diagnosis. — Acute rheumatism; organic disease of the heart; adhesion
of the pericardium.
R Pil. Hydr. gr. iij, pulv. scillae gr. ij, pulv. digitalis gr. ss, ter die
— R Inf. aurant. c. 3x, Sp. seth. nit. et sp. junip. c. aa 31, T1. hyoscyami
m x, 6tis horis. R Haust. sennse, pulv. Jalapse gr. vi, potassae supertart.
•Ji, alterno die.
He died within twenty-four hours, after an attack of haemoptysis
to a considerable extent.
Autopsy. — Universal adhesion of the pericardium. The layer of
lymph, forming the medium of adhesion, was thin and dense. The
heart was judged to be nearly three times its natural dimensions. The
enlargement was principally in the left ventricle, the walls of which
were an inch and a half thick, and the cavity larger than the largest
orange. The right ventricle was similarly affected, but in a less de-
gree. The aortic valves were thickened, nodulated and corrugated by
an opake, yellow degeneration, partly cartilaginous and partly steato-
matous. This had caused the detachment of the angular extremities
of the valves from their insertions; so that, being adherent by their
centres only, they projected loose into the artery, and were destitute
of fulcra by which to oppose the reflux of blood from the aorta.
Remarks. — The degree of enlargement which existed in this case
is seldom exceeded. There is little doubt that the affection originated
in the attack of rheumatic endopericarditis eight years before, by
which adhesion of the pericardium and the disease of the valves had
been occasioned — lesions that never fail to induce more or less dila-
tation, and generally hypertrophy. As the dilatation was so enormous,
it is not improbable that softening from the pericarditis contributed
in the first instance to its production. The thinness and density of
the lymph indicated the oldness of the adhesion; for in recent cases
the deposition is always soft, and often several lines in thickness.
The adhesion was inferred from the obvious hypertrophy with dila-
tation, the antecedence of rheumatic pericarditis, and the remarkable
movement in the epigastrium, probably occasioned by retraction, as
supposed by Dr. Sanders. This is one of the very few cases in which I
have observed this phenomenon, nor can I say that the retraction was
very distinct even here. Did regurgitation of the aortic blood conse-
quent on the disabled state of the valves, occasion the compressibility
of the pulse, noticed by Dr. Chambers? This question, written in
1829, I was soon after able to answer in the affirmative, having fully
ascertained that the eminently jerking pulse (which, though full and
CASES. 501
strong, is always compressible) is the characteristic pulse of aortic re-
gurgitation (see p. 362). At the time when this case was written, 1
was doubtful whether the pulse was referable to the adhesion of the
pericardium or to the regurgitation, as I had always met with it in
the conjoint affection.
It is manifest that regurgitation must have a powerful effect in pro-
ducing enlargement of the left ventricle; for the whole weight of the
arterial circulation, instead of being sustained partly by the valves,
rests constantly, and exerts its expanding force, upon the ventricle.
The haemoptysis depended on the state of the heart. For, as the
retrograde pressure of blood in the left ventricle had precisely the same
effect as a valvular obstruction in opposing the passage of blood from
the lungs through the left side of the heart; while, at the same time,
the right ventricle, hypertrophous and dilated, expelled a preter-
natural quantity of blood with augmented impetuosity, the delicate
vessels of the lungs, exposed to these conjoint forces operating in op-
posite directions, yielded to the pressure, and relieved themselves by
transudation of blood into the air passages. It is for this obvious rea-
son that pulmonary apoplexy and haemoptysis are more frequently
found connected with an impediment on the left side of the heart,
and simultaneous hypertrophy of the right ventricle, than with any
other lesions of the organ.
Dilatation of the heart; hydropericardium; hydrothorax. — John Snoic-
den,2dt 3S, tall, thin, sallow, with circumscribed redness of the cheeks,
was received into St. George's Hospital May 19th, 1829, with ortho-
pnea; excessive dyspnoea on the slightest exertion; cough; watery ex
pectoration; ascites; face puffed and leucophlegmatic; great cedema of
the legs; undulating or rolling motion in the precordial region; pulse
110, weak and irregular; urine scanty.
He had long been short-winded, but to no considerable degree
until two months before admission, when he was suddenly attacked
with excessive dyspnoea while walking. This symptom increased,
and in a fortnight was followed by dropsy.
Auscultation. — Resonance dull over an unusual extent of the pre-
cordial region. Impulse of the left ventricle is slightly increased, but
undulating and not synchronous with the ventricular contraction as indi-
cated by the first sound. Over the right ventricle the impulse is
weaker. Sounds, are short, flat, and audible over the whole anterior
surface of the chest. Neither coincides with the radial pulse, and
they are so much alike as to be with difficulty discriminated.
Diagnosis. — Dilatation of the left ventricle, icithout attenuation of
Us parietes; hydropericardium; hydrolhorax (ascertained by percussion.)
V. S. ad 3x — R Elaterii gr. i, calomel, gr. ij, eras mane. — Potus
supertart. potassae lb. i in die. He improved considerably for a fort-
night, when he was bled to 3x for increase of cough and slight erysi-
pelas of the face. These were mitigated, but the debility and dropsy
increased. Pulse 120 (Haust. sulph. quinae ter die. — R Haust. opiat.,
oxymel scillae et sp. aeth. nit. aa 3ss omni nocte.) In a fortnight the
cough and dropsy were greatly diminished, and he was able to leave
his bed a little.
502 HOPE ON DISEASES OF THE HEART.
Auscultation. — The impulse coincides better with the ventricular
systole, and the heart is more distinctly felt to strike the ribs. Pulse
is still weak, and not perfectly synchronous with the ventricular con-
traction. Diagnosis. — Hydropericardiwn diminished. Emaciation and
debility now made rapid strides, the dropsy began to re-accumulate,
and in another fortnight he sank.
Autopsy. — Upwards of Oij of serum in the pleura; giii or IV °*"
bloody fluid in the pericardium. Lungs. The left was healthy above,
but the inferior lobe was gorged with blood, and heavier than water.
The right contained some suppurating tubercles. Heart. Left ven-
tricle was considerably dilated, and its parietes were half an inch
thick. The right ventricle was rather less dilated than the left, and
its parietes natural, or thinner if either. Valves healthy. The apex
of the left ventricle contained a polypus which had softened or sup-
purated in its centre; and roundish nodules of lymph were found in
the interstices of the columnse carneae.
Remarks. — The short, flat and loud first sound, and the weak and
irregular pulse, indicated the dilatation; while the rather increased
action of the left ventricle, though partly attributable to the accelerated
and disturbed state of the circulation, denoted that the parietes were
not attenuated.
In cases of dilatation, when the general constitutional powers are
still tolerably good, and the increased capacity of the heart does not
greatly predominate over its muscular strength, the pulse is generally
regular, and, though soft, it has frequently a considerable degree of
fulness. But when the strength fails, as in the present instance,
or the heart is otherwise excited beyond its contractile power, the
same pulse may become both weak and irregular. The latter cha-
racter, therefore, must be regarded rather as incidental, than essential
to dilatation.
It may be inquired how, in this case, the pulse was weak, while
the action of the left ventricle was increased. This apparent anomaly
is of frequent occurrence; and, what is still more remarkable, it may
take place in cases of hypertrophy as well as of dilatation. In fits of
asthma or great dyspnoea, for example, the pulse is often scarcely
perceptible, while the heart is felt to be in a violent tumult. In other
cases, both the impulse and pulse are diminished, and nothing is then
felt in the precordial region, but an obscure, profound, rolling or
fluttering motion.
The inference from these facts appears to be, that when the heart
is congested beyond its propulsive power, its efforts are expended on
itself, without communicating strength to the pulse; and that when
the engorgement is extreme, its muscular power is more or less para-
lyzed or suspended.
In addition to its other qualities, the pulse, in. the above case, was
later than the ventricular systole. I have found this to occur in
nearly all conditions of the heart in which the blood was propelled
with difficulty, but especially in dilatation, and in contraction of the
mitral valve,
cases. 503
The hydropericardium was indicated by the undulatory nature of
the impulse; by its want of coincidence with the sound of the ventri-
cular contraction; by the sensation, communicated through the stetho-
scope, that the heart did not strike the ribs immediately; and by the
extensive dulness of the precordial region on percussion. These,
according to my experience, are the best physical signs of hydrope-
ricardium; and, when supported by general signs, they will rarely, I
believe, be found fallacious.
The polypi evince the difficulty with which the blood was circu-
lated through the heart, these formations commonly being results of
its stagnation. Their organized appearance and internal softening
a fiord reason to believe that they had existed for a considerable time.
The case presents an instance of failure of the vital powers on the
disappearance of dropsy, — a common event in aged persons, or ex-
hausted constitutions.
The bleedings practised were injudicious, as he was already too
ansemic and emaciated to bear them. Accordingly, the pulse rose,
and the debility and dropsy increased.
Simple dilatation of the heart, with softening, producing a feeble, irre-
gular pulse; pleurisy. — Patrick Qillan, act. 43, a hawker, admitted into
St. George's Hospital, under Dr. Chambers, June 24, 1S2 9. Pain
in the left hypochondrium with inexpansihility of the ribs over the
part affected; slight cough; scanty, white expectoration; decubitus
easiest on the side affected; pains in the head and shoulders; ortho-
pnoca; difficulty of respiration increased by ascending; pulse 80, feeble,
irregular, and extremely intermittent; skin cool; tongue furred and
yellow; bowels costive; urine high-coloured. Turgescence without
pulsation of the jugulars.
A fortnight before admission he was seized with general rheuma-
tic pains, stitch in the left side, and dry cough. During the pre-
ceding winter he had vomited two quarts of black blood, intermixed
with food.
(V. S. ad 5xij — R Haust. salin: cum sulph. potassse, Z\, 4tis horis,
Diaeta parciss.)
Auscultation. — No impulse that raises the head, (applied to the cy-
linder,) but a fluttering motion, with an occasional shock of some
strength. A short, flapping first sound, not much louder than na-
tural. No bellows-murmur of either sound.
Diagnosis. — Passive dilatation of the heart; no ossification of the
aortic valves, nor disease of the mitral according to the evidence of aus-
cultation; though the irregular, fluttering action, and feeble, intermittent
pulse, fac our the idea of regurgitation into the left auricle.
(Edema of the legs with scanty urine supervened. Diuretics and
purgatives with camphor and hyoscyamus were prescribed, and the
emplast. belladonna? was applied over the heart. The effect of the
medicines was satisfactory, but the constitution was worn out, and
he died a month after admission.
Autopsy. — The heart was dilated to nearly double its natural size;
the parietes were about natural, or attenuated if either, but they
504 HOPE ON DISEASES OF THE HEART.
were very flabby, and had externally a leucopblegmatic or infiltrated
appearance and feel. Valves and aorta were sound. Lungs were
gorged with blood and serum, and contained a few isolated tubercles.
The surface of the inferior lobe on the left side, and the correspond-
ing extent of the pleura costalis, were covered with old, whitish
lymph, which by its adhesions formed a sac, enclosing a pint and a
half of serum.
Remarks. — The feeble and intermittent pulse in this case led some
to suppose that there was disease of the valves. The case itself
(and it is by no means a solitary one) proves that such a pulse may
exist totally independent of valvular disease when the debility of
the heart or of the constitution is very great.
The softened state of the organ contributed to render its action
more feeble and irregular, and its sounds weaker, than might other-
wise have been anticipated from such a degree of dilatation. I have
shown in the chapter on softening that it is the attribute of this dis-
ease to produce these effects (see p. 327). Turgescence without
pulsation of the jugular veins, as in this case, is very characteristic
of a dilated or otherwise enfeebled right ventricle. "When not en-
feebled, and especially when hypertrophous as well as dilated, the
turgescence is always accompanied with pulsation. As congestion
of the venous capillaries predisposes to hemorrhage, it is probable
that the hsematemesis which occurred during the previous winter,
was attributable to this cause. The death of the patient was accele-
rated by the pleurisy, and not only by its direct effect, but by its
hurrying the action of the heart, and increasing the embarrassment
of the circulation. It is, indeed, generally by accidents of this kind
that diseases of the heart are brought to their fatal termination; and
this fact suggests an important practical lesson — that, in persons
affected with organic disease of the heart, all complaints capable of
hurrying the circulation, and especially those of an inflammatory
nature, should be regarded and treated as maladies of serious import-
ance, capable of suddenly and unexpectedly producing a series of
the most dangerous effects.
Enormous dilatation and extreme attenuation of the left ventricle; di-
latation and hypertrophy of the right; pulmonary apoplexy; enlarge-
ment of the liver. — William Lambert, set. 52, an eating-house keeper,
tall, emaciated, of exsanguine, sallow complexion, was admitted into
St. George's Hospital, under Dr. Chambers, September 6, 1829, with
pain in the chest, principally at the base of the sternum, and in-
creased by full inspiration. Cough; expectoration copious, viscous,
deeply coloured with blood; dyspnoea with cough in agonizing pa-
roxysms, induced by any exertion, particularly ascending; the right
jugulars slightly tumid, with pulsation; fluctuation of the abdomen;
slight oedema of the legs; enlargement and induration in the region
of the liver; decubitus easiest on the right side. Pulse 70, intermit-
tent, rather weak, sometimes scarcely perceptible: skin cool, tongue
furred, of cream colour; bowels costive; urine high-coloured and
scanty
cases. 505
ill nine months. Complaint began (after protracted mental anx-
iety) with cough and dyspnoea, which frequently occurred in pa-
roxysms. The ascites had existed, more or less, for two or three
months previous to admission; and the oedema of the legs for a
week only.
Auscultation. — The inferior dorsal region of the chest, on the right
side, is dull on percussion, and has a slight crepitant rale. The su-
perior lobes of the lungs are resonant, but the respiratory murmur
is puerile and bronchial. The impulse of the heart is slightly tumul-
tuous or confused, but very feeble. Sounds are little louder than na-
tural, but the first is short, like the second: they are audible at the
clavicles, especially the right.
Diagnosis. — Pcripneumony or pulmonary apoplexy of the right lung;
bronchitis; dilatation of the heart; (particularly the right ventricle?)
enlarged liver.
Cucurb. cruent. inter scapulas ad 3xij R Inf. Rosae Siss, magnes.
sulph. 3ij, sp. retheris nitric. 3ss, 6^* horis. — 1£ conf. sennse 3i, potas-
sae supertart. 3ss. omni nocte. Diaeta lactea. The symptoms were
alleviated at first; but effusion was found, by auscultation and per-
cussion, to increase rapidly in the right pleura, and the cough and
dyspnoea suffered a corresponding aggravation. When the circulation
was accelerated, the action of the heart was occasionally found to be
more vigorous than natural, though the pulse, at the same time, con-
tinued feeble and small, but tolerably regular. The sputa maintained
their deep muddy red stain to the last. Orthopncea with the utmost
distress from a sense of suffocation became constant, and the patient
expired five weeks after admission.
Autopsy. — The right cavity of the chest was filled with clear,
chlorine-coloured serum; and the lung, compressed against the spine,
was reduced to the size of a spleen. The pleura-pulmonalis was co-
vered with lymph, in honeycomb reticulations; and the pleura cos-
talis was mottled with patches of red vascularity. The compressed
lung felt doughy and non-crepitant. The margin of the lower lobe
was in the second degree of hepatization, bordering on the third, a
little pus exuding on pressure. In the midst of this was a mass of
pulmonary apoplexy, as large as an egg, claret-coloured, granular,
of great density, and bounded abruptly by a wall of straw-coloured
lymph. Similar masses existed in the other lung, with sanguineous
engorgement, but no hepatization. Heart. The left ventricle was
dilated to a capacity which would easily contain the largest orange,
or even a small melon. The parietes did not anywhere exceed a
quarter of an inch in thickness, and throughout the lower half they
varied from one to two lines. Over a small extent, near the apex,
the muscular substance was totally deficient, and the membranes alone
formed the barrier. At this part, however, the pericardium had
been thickened and strengthened by an external layer of lymph, —
as takes place over large vomicae contiguous to the pleura, and which
we cannot but regard as a wonderful provision of the Author of na-
ture to obviate sudden death, which must otherwise so frequently
12— g 34 hope
506 HOPE ON DISEASES OF THE HEART.
occur. Many large coagula of bloody fibrine lined the cavity, and
adhered tenaciously to the columnae carneae. The right ventricle was
dilated, but to a rather less extent than the left, and its parietes were
in parts four or five lines thick. Both auricles were dilated. Valves
were all sound. Aorta was slightly dilated, but otherwise healthy.
Remarks. — The feebleness of the heart's action, the brevity of the
first sound, the weakness of the pulse, and the general symptoms of
venous retardation, indicated the dilated and debilitated condition of
the heart. The occasional intermissions of the pulse, and the some-
what tumultuous or confused nature of the impulse, might have led
to a suspicion of disease of the mitral valve and regurgitation into
the auricle: but in such cases the pulse is not only intermittent, but
unequal and irregular, and it becomes remarkably so towards the fatal
termination. These, however, were not its characters in the present
instance; and as there was not, moreover, any bellows-murmur ac-
companying the sounds, valvular disease was excluded from the di-
agnosis. A sufficient cause for the intermittence and unsteady im-
pulse existed in the extreme degree of dilatation, and the consequent
labour of the heart to propel its unnatural burden. The increased
impulse of the heart, when the circulation was accelerated, proceeded
from the thickened state of the right ventricle; and to the same cir-
cumstance, together with the retardation in the left ventricle, is the
pulmonary apoplexy to be attributed. This affection was indicated
by the crepitant rale and the bloody sputa. It was the latter, how-
ever, which formed the diagnostic sign; for the stain of blood was
redder, and persisted more unchanged to the last, than occurs in pe-
ripneumony, in which affection, the sputa, though pinkish at first,
soon became rust or fawn-coloured, and even this stain gradually de-
creases as the disease advances to its resolution, or degenerates into
purulent infiltration. When, therefore, such a state of the expecto-
ration as existed in the present case, accompanies signs of obstruc-
tion on the left side of the heart, especially if conjoined with those
of increased action of the right ventricle, pulmonary apoplexy may
be anticipated. The tenacious coagula adherent to the left columnae
carneae evinced that the circulation through the ventricle had been
languid. These formations, when they choke the cavities, cause a
remarkable aggravation of dyspnoea, and by this they may often be
recognised for a week, or even longer, before death, the patient
having a constant agonizing feeling of imminent suffocation. The
enormous size of the left ventricle caused it to occupy a more central
situation than natural. Its sounds, therefore, being more audible at
the base of the sternum than in the left praecordial regiom the dilata-
tion was supposed to be greater on the right than on the left side.
Laennec experienced and pointed out this source of fallacy (torn. ii.
507). its rarity renders it unimportant. The pulsation of the ju-
gulars is to be referred to the hypertrophy of the right ventricle;
and the enlargement of the liver found its origin in congestion re-
sulting from impeded circulation through the heart.
CASES. 507
Hypertrophy and dilatation of both ventricles; dilatation of
the aorta; roughness of its interior; bad effects of excessive blood-
letting.— Henry Macearl, set. about 45, an old soldier, tall, meagre,
sallow, and livid when cold, was received into St. George's Hospital,
October 28, 1S29, with orthopnoea, impulse of the heart stronger,
lower, and more extensive than natural; occasional pain in the left
side, when attempting to lie upon it; somnolency: languor; no drop-
sy ever; pulsation of the carotids; pulse 116 — a jerk, followed by
full, strong and vibrating tension, — regular; tongue white; bowels
open.
Eighteen months previous to admission he received a kick from
a horse on the precordial region, which gave rise to his complaint.
Auscultation. — Resonance of the precordial region is rather dull:
that of the chest elsewhere, good. Impulse, very powerful above
the clavicles, especially opposite to the arteria innominata. It is ac-
companied with purring tremor, and a loud, hoarse, abrupt bellows-
murmur, which, when traced downwards along the sternum, be-
comes more hissing, and, as it were, superficial. It retains the same
characters, though somewhat stifled, in the precordial region, where
it drowns the natural sound of the ventricular contraction. The im-
pulse of the heart is much stronger than natural, and is followed by
a vigorous back-stroke.
Diagnosis. — Hypertrophy and dilatation of the heart; dilatation of
the aorta; disease of its internal coat, from the aortic valves to beyojid
the arch. Fiat V. S. ad %x, segro recumbente. R Tr opii m xxx,
mist, camph. 3x. Diaeta lactea.
In the course of ten weeks he was sparingly bled six or seven
times, as he stated it to be "the only thing that afforded him relief."
He also took various formulae of opium, aether, Infus. Digitalis, Ext.
Lactucae, and aromatics; but they had little effect, and he progress-
ively declined. CEdema of the lower extremities supervened, with
constant orthopnoea; pain in the precordial region; ghastly paleness,
without lividity, of the face; frequent paroxysms of dyspnoea; and
extreme anxiety and distress. He died Jan. 15, 1830.
Autopsy. — The left ventricle was three-fourths of an inch thick,
and its cavity was dilated to one half more than its natural size. The
right ventricle was equally dilated, but only slightly thickened.
Valves were healthy, except that the aortic were a little cartilaginous,
but perfectly flexible. Aorta was somewhat dilated; and the whole
of its inner surface, from the valves to beyond the arch, was rendered
extremely rough by steatomatous or cheese-like degeneration, de-
posited in great abundance. Patches of the same wrere found as low
as the pelvic divarication.
Remarks. — The violence of the heart's action, and the strength of
the pulse, left no doubt of the hypertrophy: and the dilatation was
denoted by the extent of the impulse, the deficient praecordial reso-
nance, and the fulness of the pulse. The dilatation and roughness of
the arch of the aorta were indicated by the impulse, sound, and tremor
above the clavicles; and the ascending aorta was presumed to be in
508 HOPE ON DISEASES OF THE HEART.
the same state, from the existence of the same sound along its course,
only more hissing from the greater contiguity of the artery to the
ear, and the interposition of a less resonant medium. It is apparent
from this case, that a murmur generated in the aorta, may extend to
the heart and obscure its sounds. Caution is, therefore, requisite not
to mistake it for a result of valvular disease. The diagnosis is given
at p. 366.
The vigorous back-stroke is to be remarked as a concomitant of
hypertrophy with dilatation; the purring tremor of the pulse, as a
consequence of powerful propulsion of the attenuated blood through
a rugged aorta: and the extreme severity of the dyspnoea, as a result
of the complication of disease of the aorta with that of the heart, in
an asthmatic subject. This was, in short, one of the worst forms of
cardiac asthma.
The case strongly exemplifies the bad effects of excessive blood-
letting. He was bled six or seven times in ten weeks: the result
was, ghastly paleness (anaemia), dropsy and progressive decline.
Great hypertrophy with dilatation of the left ventricle; ossification of
the aortic valve; chronic pericarditis with effusion; hemiplegia and apo-
plexy.— Richard Porter, set. 52, a cook, of small stature, pale, emaci-
ated, was admitted into St. George's Hospital, under Dr. Hevvett,
April 8th, 1829, with hemiplegia of the left side; mouth distorted to
the right, but partial paralysis of both sides of the face; a sensation
of fulness and tightness about the inferior part of the sternum; cough;
starting from sleep in a fit of palpitation and suffocating asthmatic
dyspnoea; anasarca; pulse 96, full, and tolerably firm and regular.
Ten years before admission he had apoplexy and hemiplegia of the
left side, which disabled him for half a year. He then resumed his
work as a cook, and prosecuted it until three weeks ago, when he
took cold, and became affected with anasarca, to which he had been
subject. With this account of the early history I was favoured by
Dr. Hevvett, under whose care the patient was admitted. I did not
see him till July 2.
Auscultation, three months after admission. Very loud rasping
murmur. (A momentary examination.) Diagnosis. — Disease of the
valves of the heart. He died eight days afterwards, in consequence of
a fit of apoplexy.
•Autopsy. — Head. A small coagulum of blood under the dura
mater, at the vertex of the brain, and three or four ounces of serum
at the base. Chest. In the cavities of the pleura were upwards of
three pints of serum; and in the pericardium was above a pint, deeply
coloured with blood. The whole interior of the sac, and the surface
of the heart, were invested with a thick stratum of shaggy, and highly
vascular, reddish lymph. Heart. The left ventricle was thickened
to almost double— or to nearly an inch; with general dilatation of
the heart. Aorta. Its internal membrane was slightly corrugated
by steatomatous degeneration, intermixed with a few calcareous scales.
Valves. The edge of one of the aortic valves was encumbered with
an osseous concretion as large as a pea, of an elongated form, project-
CASES. 509
ing into the artery, and with an irregular, denuded and scabrous
surface.
Remarks. — Though the details of this case are defective, it is, not-
withstanding, one of great practical value. It demonstrates that a
very considerable impediment in the aortic valves does not necessarily
prevent the pulse from being full, and tolerably firm and regular,
the reverse of which was believed by the old writers, particularly
Corvisart, who has been followed by Louis, Bouillaud and almost all
other authors (seep. 361.) It shows that a scabrous ossification
occasions not only a loud murmur, but one of a rasping or grating
character. The case, furthermore, presents one of the numerous
instances of palsy or apoplexy connected with hypertrophy of the
left ventricle; and, as an interval of ten years had elapsed between
the first and second paralytic attack, during which he had continued
at his accustomed avocations, it shows with what an extent of disease
of the heart the functions of life may be maintained. Steatomatous
and calcareous disease of the aorta is so frequently accompanied with
hypertrophy of the left ventricle, that it is natural and rational to
regard the latter as a result of the obstacle to the circulation presented
by the former. But, on the other hand, the frequent occurrence of
the same disease in the arteries of the brain when the left ventricle
is hypertrophous, leads to the inference that over-distention may
occasion it, (see p. 259,) and, consequently, that its existence in the
aorta may sometimes be secondary to the hypertrophy of the ven-
tricle. On either view, the diseases described, of the aorta and of
the heart respectively, are cause and effect, and hence, the practical
deduction is, that, when either exists, it is requisite to keep the cir-
culation tranquil, in order to prevent the development of the other.
The chronic pericarditis probably took its date from the attack of
cold three weeks before his admission, and occasioned the sensation
of fulness and tightness about the inferior part of the sternum. It is
not unusual to find bloody fluid effused by organized lymph of the
pericardium, especially when, as in the present instance, this mem-
brane is in a state of chronic inflammation.
Simple hypertrophy; contraction of the aortic valve to the size of a small
pea; asthmatic fits about noon daily. — Wm. Hedgley, aet. 10, was ad-
mitted into St. George's Hospital, under Dr. Hewett, April 17, 1830,
with respiration very hurried; temporary pain and constriction in
the praecordial region; extensive pulsation of the heart; slight cough;
oedema around the eyes; daily febrile accessions with palpitation,
coming on about noon, and consisting of chilliness for an hour, heat
for half an hour, and perspiration till evening; pulse 120, very small,
weak and unequal; tongue thickly furred, moist; skin cold, perspira-
tion: bowels regular; urine scanty, dark and thick.
Did not complain until seven weeks ago, when the parox)sms,
accompanied with pain at the heart, first attacked him (endocarditis?).
Auscultation. — Resonance of the chest natural. Impulse of the
heart increased. Sound of the ventricular contraction is that of
sawing (bruit de scie). He died three weeks after admission, namely,
34*
510 HOPE ON DISEASES OF THE HEART.
May the 11th. I was favoured with the notes of this case by Dr.
Hewett, as I did not see the patient until the post-mortem examina-
tion.
Autopsy. — Walls of the left ventricle were upwards of half an inch
thick, and very firm; those of the right were slightly thickened; both
cavities were about natural. The aortic aperture was contracted by
fibro-cartilage to the size of a small pea. Two ounces of serum in
the pericardium, and six in each pleura. Lungs, at the lower parts,
were congested and somewhat condensed.
Remarks. — The disease of the valve was clearly indicated by the
sawing-murmur, and the hypertrophy by the increased impulse.
The case proves that an extreme degree of contraction of the aortic
valves renders the pulse small, weak and unequal; while the pre-
ceding case proved that a moderate degree had not that effect. The
valvular contraction was manifestly referable to the endocarditis ten
weeks before death, and the case displays how rapidly so serious a
lesion may be occasioned by inflammation.
Why the intermittent febrile paroxysms occurred at the same hour
daily, is not very apparent, unless the patient had been under the
influence of malaria, which I could not ascertain. In the case of
May, the paroxysm occurred at the same hour every night.
Dilatation of the heart: ossification and slight dilatation of the ascend-
ing and descending aorta, dilatation of the bronchi; hydrothorax; ossifi-
cation of the cerebral arteries. — Richard Slorer, aet. 73, feeble and
decrepit, was received into St. George's Hospital, July 8th, 1829.
Hissymptoms were, palpitation; dyspnoea, aggravated by the slightest
exertion; respiration extremely wheezing; cough; copious expecto-
ration; universal dropsy ; jugular veins turgid without pulsation; pulse
90, full, strong, and tense.
Subject to a chronic cough for fourteen years. Swelling of the
face came on ten weeks before admission, and was followed by that
of the feet, scrotum, &c.
Auscultation. — Slight pulsation and soft bellows-murmur above the
clavicles; impulse of the heart not perceptible to the hand, and it can
only be felt occasionally by the cylinder. Its power is then consi-
derable, but it is rather a blow, than a heaving of the thoracic parietes„
Sounds. — both are short and flat; neither is very loud, but the second
is the louder. Excessive mucous rales in the chest, which obscure
any murmurs of the heart. (Bruit de soufflet was distinguished at a
subsequeut examination by Mr. Johnson.) At the lower part of the
left scapula there is loud pectoriloquy and gurgling rale.
Diagnosis.— -Dilatation of the heart; no aneurism, nor appreciable dila-
tation of the arch of the aorta. Hydrothorax and dilatation of the bronchi
on the left side.
R pil. Hydr. gr. iij, pulv. scillae gr. i. pil. ter die sum. — R potus
potasste super-tart. Oj quotidie — R elaterii gr.. ss, hydr. submuriat
gr. ij, alterno quoque mane sumend.
In three weeks the dropsy was greatly reduced, but as the legs
continued (Edematous, slight incisions were made with the lancet in
CASES. 511
the calves, by which the fluid was evacuated, and a considerable
quantity of blood lost. After this, his strength gradually failed, and
he sank in four days.
Autopsy, for the account of which I am indebted to Mr. Johnson. —
Heart was very large. All its cavities were dilated. The parietes
of the left ventricle were about natural, or perhaps thicker. Valves
healthy; but there were slight calcareous depositions beneath the
bases of the aorta, and under the internal membrane of the heart, be-
tween the aorta and the mitral orifice. Aorta. No dilatation of the
arch; but some in the ascending portion, immediately before the
branches; and again, beyond the origin of the left subclavian. Osseous
depositions, underneath the lining membrane, were scattered gene-
rally throughout the aorta and great branches; and at the mouth of
the left subclavian, a denuded patch was found. Brain. The arteries
were diseased; especially the basilar, which was very large and rigid.
Lungs. The left cavity of the chest contained upwards of a pint of
fluid; and the lung, compressed and collapsed, was imperfectly crepi-
tant, and so dense as to sink in water. This condition was most
marked, opposite to the inferior half of the scapula; to which part,
and above, the lung was inseparably adherent. The bronchus
entering the portion of lung, divided into many large branches; all
of which were drawn, by the adhesion of the pleura, into close appo-
sition with the thoracic parietes; and one, not larger than a writing
quill, was dilated at its extremity to the dimensions of a small nut.
The left lung was cedematous above, and congested with blood below.
Remarks. — The signs of dilatation were, the feeble impulse, and
the short, flat sound of the ventricular systole. The more vigorous
impulse occasionally felt, and the strength and tension of the pulse,
indicated that the muscular power was still considerable: in other
words, that the walls of the left ventricle were not attenuated. In a
young and robust subject, such a heart produces increased impulse, as
in the case of Dolan. The remarkable wheezing of the respiration,
led the attending physician and others to the suspicion of aneurism
or of great dilatation of the arch of the aorta, these affections some-
times producing that symptom by pressure upon the trachea. It
was in reftrence to this opinion that I gave an opposite one in the
diagnosis. The contra-indications were, the want of strong pulsation,
purring tremor, and loud rasping sound above the clavicles. The
slight impulse and murmur which existed there, were owing, the
former, perhaps to the throbbing of the subclavians; the latter, to the
ossification of the interior of the aorta and the dilatation below the
innominate. The dilatation of the ascending aorta might have been
recognised by tracing the murmur down the sternum, had not the
loudness of the pulmonic rales rendered this impossible. Dilatation
of the bronchi was inferred, because, as he exhibited no signs of
phthisis, the pectoriloquy and gurgling rale could not be attributed to
vomicae. The idea was, further, countenanced by his having been
subject to a chronic, asthmatic cough for fourteen years, when at an
extremely advanced age: circumstances peculiarly favourable to the
512 HOPE ON DISEASES OF THE HEART.
production of bronchial dilatation. Disease of the cerebral arteries
may here be remarked as accompanying enlargement of the heart
and ossification of the aorta. The ossifications I should ascribe to
his advanced age. The effects of the elaterium were good,- but it is
a remedy which cannot be given with impunity to subjects so old
and enfeebled as the present, without constant watching and great
discretion on the part of the practitioner.
After rheumatic endocarditis, dilatation of all the cavities, with natural
thickness of the parietes; vegetations of the left auricle and mitral valve,
causing regurgitation; superior cuspis of the mitral valve across the aortic
orifice; contraction of the aorta. — John Dolan, ast. 28, a servant, of ro-
bust frame aud pale, delicate complexion, was admitted into St.
George's Hospital, under Dr. Chambers, May 27, 1829, with palpi-
tation, increased on exertion; orthopnoea; cough; thick, white sputa;
decubitus on either side; undulation of the jugulars; slight oedema of
the legs; pulse 110, small, and very weak; bowels regular.
Five weeks before admission, he took cold while travelling, and
was seized with pain at the heart, and cough (endocarditis?). He
was bled, and a few days ago cupped, with relief. (Edema has only
existed a week. Had rheumatic fever two years ago, and several
times previously.
Auscultation. — Resonance of the precordial region, dull over a very
large extent. Impulse much stronger than natural, and felt far beyond
the usual limits and in epigastrio. Sounds are louder than natural;
especially the second in the left precordial region: the first is re-
markable for a strong, but not grating bellows-murmur, most distinct
on the left side.
Diagnosis. — Hypertrophy and dilatation of the heart; dilatation of the
left auricle; obstruction, probably cartilaginous, in the aortic orifice. Em-
plast. Lyttse regioni cordis. — R Haust. salin., Tr Hyoscy. 3ss, 6s
horis. — Dieeta lactea. He subsequently took, in various formulae,
calomel, haust. sennae, sp. 83th. nitric, Tr Digitalis, et acet. potassae.
The emplast. opii was applied over the heart. But, in a fortnight,
the oedema and ascites had made progress; and in another week he
was confined to bed, with constant drowsiness and profuse perspira-
tion, which, in two days, were followed by extreme intumescence of
the face. These symptoms persisted five or six days more, when he
became incoherent, stupid, and, finally, comatose; in which state he
expired, June 29.
Autopsy. — Both ventricles dilated. Walls of natural thickness.
Both auricles also dilated ; the left to more than double, and its interior
is covered, over an extent of two square inches, with small cauli-
flower vegetations. These likewise pervade the whole of the mitral
valve and the chorda? tendinese, rendering the margins of the valve
so thick and knotty, as to prevent them from closing accurately.
The closure is further impeded by contraction of the chordae. The
right cuspis of the valve is displaced in such a manner as to extend
across the aortic orifice and obstruct the egress of the blood. Mitral
orifice, from the auricular side, expands perhaps too widely in con-
cases. 513
sequence of the dilatation of both cavities. Jlorta. Valves healthy,
but the artery is remarkably contracted throughout, and, half an inch
in front of the left subclavian, it is corrugated. Lungs cedematous
and gorged with blood. Two small portions intensely dark, gra-
nular, and so dense, as to sink quickly in water (pulmonary apoplexy).
Brain contained an ounce of serum; and pericardium, half an ounce.
Kidney, large and pale.
Remarks. — This case proves, that if dilatation be accompanied with
a natural thickness of the parietes, :t produces the symptoms of hy-
pertrophy: viz. increased action. This holds true, however, only in
reference to young or robust subjects, — not to the old, or otherwise
enfeebled (as Storer). The great degree of the enlargement was
indicated by the extent of the impulse, and of the dulness on per-
cussion.
The murmur which attended the ventricular contraction, was oc-
casioned, not only by the position of the cuspis of the mitral valve
across the aortic orifice; but also by the patescence of the mitral
valve itself, and the consequent regurgitation into the auricle. The
second sound was not accompanied with murmur, because the valve
expanded widely from the auricular side; and the sound itself was
unusually loud, because the recoil of the semilunar valves was im-
petuous. The regurgitation, together with the aortic contraction, ac-
counted for the smallness and weakness of the pulse; and the retar-
dation of the blood, thus occasioned, led to the dilatation of the left
auricle, and eventually to that of the right cavities. The increased
action of the right ventricle, conspiring with the obstruction on the
left side, occasioned the engorgement and apoplexy of the lungs. The
drowsiness terminating in coma, is to be attributed to venous con-
gestion, of which the sudden infiltration of the face was an indication.
This congestion was probably increased by the extreme engorgement
of the lungs; and its fatal consequences display the formidable nature
of a complication which peculiarly favours such congestion: namely,
increased power on the right side of the heart, and an obstruction on
the left.
Inflammation on the internal membrane of the heart and aorta,
occasioned by the frequent rheumatic fevers, was the cause of the
vegetations of the heart, and the puckering and contraction of the
aorta.
Hypertrophy and dilatation; adhesion of the pericardium; contraction
of the mitral and aortic valves, with regurgitation through both. Hemi-
plegia. Previous endopericarditis. — Benjamin Payne, set. 37, a basket-
maker, of pale, leucophlegmatic complexion, was admitted into St.
George's Hospital, under Dr. Hewett, October 8th, 1S29, with dys-
pnoea and palpitation on every exertion, and occasioned in the night
by lying in an uneasy position; cough; puffy swelling of the face; no
oedema pedum at present, but is subject to it; sense of constriction
across the epigastrium; pulse rather small and weak, slightly vibrating,
regular now, but it sometimes intermits every alternate beat; urine
free,
514 HOPE ON DISExYSES OF THE HEART.
For many years slightly short-winded on ascending. Fourteen
months before admission had hemiplegia of the left side, which,
thou'gh cured, left his present symptoms.
Auscultation. — Resonance deficient in the precordial region, which
is unnaturally prominent. Impulse is of a curbed or struggling nature,
and is felt in epigastrio. It is an occasional shock with little heaving,
and its force in general scarcely exceeds the natural standard; but oc-
casionally it has a vigour considerably greater, and accompanied with
a back-stroke. Sounds. A prolonged bellows-murmur accompanies
both, and the two are continued into each other. The flapping of the
second is more audible on the second or third ribs than lower down.
The impulse and first sound are synchronous. Above the clavicles
there is a hoarse, but subdued and remote sound, and a very slight
pulsation.
Diagnosis. — Moderate hypertrophy and dilatation of the heart. Dis-
ease of the valves. His symptoms were much mitigated by the usual
remedies, particularly by occasional small bleedings: but they con-
tinually recurred in an aggravated form, and he sank December 19.
Autopsy. — Adhesion of the pericardium. Left ventricle nearly an
inch thick, and its cavity dilated to one-half larger than natural. The
right ventricle slightly hypertrophous, and its cavity enlarged, but
not to the same extent as on the opposite side. The mitral valve con-
verted, by cartilaginous thickening, into a rugged, knotty ring, not
more than half the natural size. Aortic valves, likewise thickened
by knotty cartilage. Corpora sesamoidea, enlarged to the size of small
peas, considerably obstruct the aperture. Interior of the aorta is
slightly steatomatous, but smooth. Lungs do not collapse, and are of
immense size from sero-sanguineous engorgement. Some fluid in the
cavities of the pleura.
Remarks. — The enlargement of the heart was indicated by the
prominence and dull resonance of the precordial region, and by the
pulsation reaching to the epigastrium. The hypertrophy was denoted
by the occasional vigour of the shock, and by the back-stroke. The
irregularity of the heart's action was attributable to the valvular dis-
ease. Although the struggling nature of the impulse was very cha-
racteristic of adhesion of the pericardium, the idea was discounte-
nanced by the history, which, according to the patient's account of
it, did not supply evidence of antecedent pericarditis. Co-existent
endocarditis was the cause of the valvular disease. It was indicated
by the murmur of both sounds. That of the first was occasioned not
only by the state of the aortic valves, but also by regurgitation through
the mitral. The murmur accompanying the second sound, resulted
from aortic regurgitation. The flapping of the second sound at the
second and third ribs, proceeded from the semilunar valves. The
smallness, weakness, and intermission of the pulse proceeded from
the mitral regurgitation, and its vibration, from the aortic regurgita-
tion. The jerk which properly characterizes the latter, was neutra-
lized by the want of a fulcrum in the mitral valve. This was a case
of cardiac asthma.
cases. 515
Dilatation and ramollissement of the heart; great contraction of the tri-
cuspid, and still more of the mitral valve, with regurgitation through each;
no murmur with the second sound; hydropericardium. — Christian Ander-
son, set. 42, in the Edinburgh Royal Infirmary, June 16th, 1825.
Cheeks, nose, and lips purple; turgescence and undulation of the
jugulars; dyspnoea, occasionally in paroxysms induced by cough or
an}7 exertion; starting from sleep, and frightful dreams; oedema of the
face and legs; pulse imperceptible; urine scanty, and high.
Eighteen months before admission, she ''strained herself opposite
to the navel," by carrying heavy weights: haemoptysis ensued and
lasted three weeks, attended with palpitation, dyspnoea, and cough.
Auscultation. — Impulse an irregular succession or undulation of the
chest. Sounds. The first (at the lower extremity of the sternum)
was a very loud filing-murmur, or that of obscured or subdued saw-
ing. It commenced abruptly, with a flap. The second sound, short
and flat, was so weak as scarcely to be audible. It concluded the first
murmur. The same sounds existed on both sides of the heart, but
were more subdued and indistinct on the left. They were more or
less audible over the whole anterior surface of the chest.
Diagnosis. — Much disease of the valves; dilatation of the heart, par-
ticularly on the right side; parietes flaccid, not thickened.
Autopsy. — The heart was nearly twice its natural size. Right auricle
and ventricle much dilated: the latter larger than an orange. Parietes
of both of natural thickness, but the ventricular columnae carneas en-
larged. Muscular substance firm but pale. Left ventricle. Its cavity
enlarged to the size of a goose's egg. Walls of natural thickness,
but pale, flaccid, and easily lacerable. Left auricle slightly thickened
and dilated. Tricuspid valve an uneven thick cartilaginous ring,
which admitted the middle finger. Mitral valve was a similar ring,
as thick as a crow-quill, admitting the end of the little finger. Pul-
monic and aortic valves were natural, except that the corpora sesamoi-
dea of the latter were enlarged and cartilaginous, but not so as to pre-
vent the valve from discharging its function. The pulmonary artery
was somewhat dilated. Pericardium contained Svij of serum ; and the
cavities of the pleura about Ov or vi. Lungs oedematous, and slightly
tuberculous.
Remarks. — To the original notes of this important and instructive
case — the first in which regurgitation was ever noticed, Laennec,
Bertin, iiouillaud and ail other authors having overlooked it — is an-
nexed the following remark: — "As the pulmonic and aortic valves were
equal to the discharge of their function, the (filing) sound proceeded from
regurgitation through the auricular valves. Hence, if 'bruissement9 be
heard during the ventricular contraction, we are not necessarily to infer,
that there is disease of the aortic or pulmonic, rather than of the auricular
valves.,y It might be objected to this argument, that the enlarged
corpora sesamoidea of the aortic valves were capable of occasioning
the murmur of the first sound. To this we may reply in the nega-
tive; as the current of blood through the aortic valves was too feeble
to excite a murmur, since it was incapable of creating a perceptible
pulse.
516 HOPE ON DISEASES OF THE HEART.
The greater weakness of the murmur on the left side, appears to
*ne attributable to two circumstances: — 1st. The smallness of the
mitral aperture; in consequence of which the quantity of fluid retro-
pelled, was inconsiderable. ' 2nd. The ramollissement of the left
ventricle: whence the retropulsion of the fluid was languid. The de-
ficient supply of blood, the mitral regurgitation, and the inadequate
power of the ventricle, account for the imperceptible pulse. On the
right side of the heart, the ventricle was stronger, and the aperture of
the tricuspid valve was double the size. Hence, the murmur was
louder.
The second sound was scarcely audible. This is what we should
expect: for the scanty supply of blood in the aorta would not close
the semilunar valves with sufficient force and velocity to occasion
much sound. Nor was this second sound accompanied with murmur; a
fact which, in the first edition of this work, I ascribed to the circum-
stance that, as the ventricles, in consequence of their dilatation and
ramollissement, possessed little resilient power, the blood, deprived
of their suction, passed indolently through the valves. But I have
subsequently met with numerous cases, including the two next, in
which the murmur was deficient, though the ventricles were healthy;
whence 1 am led to the conclusion, contrary to Laennec and all other
writers, that the diastolic current is naturally too weak to occasion
much, or sometimes any murmur, when the auricular orifices are con-
tracted (see p. 102). Laennec's error originated in his mistaking the
murmur of aortic regurgitation, which I have shown (p. 100) to be ex-
ceedingly common, for that of mitral contraction.
It was reflection on this case that led me to doubt the inferential
explanation of the second sound which I broached in the first edition
of this work, and that gave origin to the researches (p. 48) which
issued. in the experiments (p. 54,) demonstrating the real source of
the second sound to be the semilunar valves.
The undulating motion of the heart was occasioned by hydroperi-
cardium.
The next case also proves mitral regurgitation and murmur, and
the absence of murmur with the second sound.
Mitral regurgitation with murmur; but no murmur with the
second sound. — Elizabeth Dennis, set. about 50. Emaciated, ad-
mitted into the St. George's Infirmary, under Sir James Clarke, De-
cember 8th, 1S30.* Affected with all the symptoms of organic dis-
ease of the heart in their most severe form. Has been affected with
ascites and anasarca. Bellows-murmur accompanying the first sound
below the middle of the heart, but not in the region of the aorlic
valves. Impulse strong; pulse irregular, unequal and extremely
feeble, later than the ventricular systole.
Diagnosis. — Hypertrophy and dilatation. * If there is no dis-
* Sir James Clarke kindly invited me to see this case. I wrote the physical signs
with the diagnosis in his journal, from which I now transcribe them.
cases. 517
ease of the aortic valves, the bellows-murmur is from regurgita-
tion through the mitral. Is it a ring?
Autopsy. — (Performed in the presence of Sir J. Clarke, Mr. How-
ship, Mr. Syme, house-surgeon to the Infirmary, and the writer.)
Hypertrophy and dilatation of the heart. All the valves healthy ex-
cept the mitral, the free margin of which was thickened by fibro-
cartilage, and the chordae tendineae were shortened in such a manner
as not to allow the layers of the valve to come in apposition: hence
a space, judged to be about as large as a finger, was left, through
which regurgitation could take place.
Remarks. — This case affords evidence, which will, I conceive, be
considered unequivocal, that regurgitation through an auriculo-ven-
tricular valve occasions murmur with the first sound ; also, that it pro-
duces a feeble, irregular, and unequal pulse. The next case proves
the same.
Aortic valves rigid; mitral, extremely cartilaginous and ossified,
with regurgitation and murmur, but no murmur with the second
sound; tricuspid cartilaginous; great dilatation. — Geo. Sharpe,
set. 33, sallow, with livid palpebral, was admitted into St. Bartholo-
mew's Hospital, under Dr. Latham, June 7, 1826. Symptoms were,
great palpitation and dyspnoea, sometimes occurring spontaneously;
great oedema pedum; congestion and undulation of the jugulars; som-
nolency: pulse 130, weak, irregular, and intermittent. Urine scanty
and high.
Short-winded, so that he could not run up stairs, for eight or ten
years. For three or four years has had a constant short cough, with
great proclivity to bronchitis. Has been much worse since a severe
cold contracted six months ago.
Auscultation. — Resonance of the praecordial region extensively
dull. Impulse, though feeble, is felt from the fourth to the eighth
rib. Below the left nipple, the shock is somewhat stronger than na-
tural. Sounds. The first is a grating combined with a whizzing
murmur, which, over the left ventricle, is loud and near to the ear;
while, over the right, it is as if remote. In the latter situation the
flapping of both sounds is remarkably loud. The second sound, on
the left side, is without murmur.
Diagnosis. — Dilatation and hypertrophy of the left ventricle, but
walls not appreciably thickened. Right ventricle and auricle dilated,
but not hypertrophous. Valvular disease on the left side. On the
right side also? (If the event disprove this, does the murmur heard
on the right side proceed from the left?)
Autopsy. — 3ij or iij of serum in the pericardium; Oij in the chest,
and as much in the abdomen. Heart enlarged to nearly double.
Right ventricle would contain a large lemon; its walls were less than
one-fourth of an inch thick, but the columnae were enlarged. Auri-
cular orifice considerably widened. Loose margin of the tricuspid
valve cartilaginous and thickened, but it wasjudged capable of closing
the aperture. Left ventricle would contain a small lemon: walls half
an inch thick at the base, and a quarter at the apex. Aortic valves
12— h 35 hope
518 HOPE ON DISEASES OF THE HEART.
very rigid with cartilage. Mitral valve extremely diseased. The
base and margin were of fibro-cartilage, intermixed with denuded
bone. A lamellated polypus of organized lymph, as large as a walnut,
grew in the auricle by vascular connexion with the lining membrane,
which was rough, opake, and yellow.
The internal coat of the arteries was stained of an intense red.
Remarks. — The extensive dulness, the languid impulse, and the
loud napping sound of the ventricular contraction, denoted the dilata-
tion; while some degree of power in the shock below the left nipple,
indicated that the walls of the ventricle were not attenuated. The
valvular disease on the left side was denoted by the murmur. The
compound nature of the murmur, partly whizzing and partl)r grating,
indicated that both valves were affected. I have frequently met with
this compound species of murmur, the whizzing character appertaining
to the aortic valves, in consequence of their being nearer the surface.
This is well exemplified in another individual at present under my
notice, affected with disease of both valves, in whom there are from
two to fiVe beats of the heart accompanied with grating murmur, but
no pulse in the radials: then succeeds a stronger shock with a pulse,
and a hissing opposite to the aortic valves.1 In the present case, the
grating sound, the feebleness and instability of the pulse, and the ge-
neral symptoms of obstruction on the left side of the heart, left little
doubt that there was regurgitation through the mitral valve.
Why was not the second sound, or that synchronous with the left
ventricular diastole, accompanied with murmur from the contracted
mitral? Because the diastole is not usually attended with a suffi-
ciently copious and rapid passage of blood to occasion a murmur.
The following case shows that contraction of the mitral valve, when
extreme, and attended with attenuation and softening of the left ven-
tricle, may not be attended with murmur of either sound.
Dilatation and softening of all the cavities: hypertrophy of the
right ventricle; attenuation of the left; great contraction of the
mitral valve; fatal polypus. — Mrs. — / — n consulted me Dec. 27,
1829. She had livid lips; a defined purplish red on the cheeks: com-
plexion elsewhere sallow; dyspnoea and palpitation, excited even by
walking across a room, and to excess by ascending a flight of stairs;
frequent cough, preventing sleep; constant copious expectoration of
frothy, viscous mucus, the temporary suppression of which, by sleep
or opiates, caused paroxysms of excessive dyspnoea and orthopncea;
chilliness, particularly of the extremities; universal and extreme
anasarca; catamenia regular; bowels open; pulse small, weak, unequal,
and intermittent; urine scanty and high; thirst; anorexia.
Complaint commenced ten years before I saw her, and was attri-
buted to difficult parturition. The symptoms were always greatly
aggravated by colds, to which she was particularly liable. She had
frequently had slight oedema pedum, which subsided spontaneously.
Always felt best in a warm, humid atmosphere.
1 M. Bouillaud states that he was the first who noticed this variety of intermission.
He is mistaken, as the present case is long anterior in date to his publication in 1835.
CASES. 519
Auscultation. — Impulse imperceptible. Sounds. Both were
short, flat, and audible as far as the right clavicle. They were
weaker on the left side of the heart. Murmur was not noticed.
By the usual diuretics and aperients, the dropsy was completely re-
moved in six weeks, the strength being little impaired and the ap-
petite good. She was then suddenly seized with oppressed palpita-
tion, suffocative orthopnea, constant nausea, and over-powering ex-
haustion, anxiety and jactitation. The dropsy began to re-accumu-
late, the sense of suffocation became agonizing, the pulse failed en-
tirely for twenty-four hours before death, and she sank a week after
the relapse.
Autopsy. — Pulmonary apoplexy and engorgement. Heart double
the natural size, and very flaccid and pale. Ventricles. Right di-
lated to double; its parietes were not attenuated, and the columnas
carneae were hypertrophous. The left was less dilated, and its walls
were reduced to one-third of an inch in thickness. Auricles. Right,
dilated; its parietes thin and diaphanous. Left, greatly dilated, con-
siderably thickened, and almost completely filled with a polypus ad-
hering firmly to its lining membrane. Valves. Aortic, slightly car-
tilaginous, but unimpeded. Mitral, contracted by cartilage into a
slit which only admitted a writing quill. Sv of serum in the peri-
cardium. Liver slightly enlarged, granular, and of yellowish brown
colour.
Remarks. — This case is remarkable as presenting a degree of val-
vular contraction seldom if ever exceeded, and as showing with how
great an amount of disease life may be prolonged for a series of
years.
The dilatation was manifest from the deficient impulse, and the
short, flat sounds. Though no murmur was noticed on the left side
of the heart, contraction of the mitral valve was inferred from the
small, weak, unequal, and intermittent pulse, and from the languid
action of the left ventricle: as, however, 1 have since ascertained
that a similar pulse and impulse, together with venous retardation,
may be occasioned by softening independent of valvular disease, the
latter must not be confidently inferred unless there is a murmur.
The reason why great contraction of the mitral, such as existed
in the present case, should not always produce murmur, is ex-
plained p. 102.
The eolu mnae earner of the right ventricle were hypertrophous.
This, concurring with the obstruction of the mitral, accounted for
the pulmonary congestion and apoplexy. Hence, too, the copious
expectoration; which being the mode that nature adopts to unload
the vessels of the lungs, it is obvious why the symptoms were ag-
gravated when the expectoration was suppressed, whether by opi-
ates, catarrh, or a dry, sharp air. The relapse occurred at that criti-
cal moment when the dropsy had disappeared: the sudden superven-
tion of suffocative dyspnoea, &c. renders it probable that the pol}Tpus
in the left auricle commenced at that time, and was the cause of the
symptoms and of the fatal event. Hence the importance in such
520 HOPE ON DISEASES OF THE HEART.
cases of preventing nausea, syncope, or any affection which can
cause stagnation of the blood. (See Polypus).
The following case presents a beautiful instance of
Recent lymph or vegetations on the tricuspid valve, from acute endocar-
ditis.— Ann Fenn, a patient admitted into St. George's Hospital, in
April 1839, was represented to me by students who took notes of
the case, to have exhibited the symptoms of acute endopericarditis,
and to have died during the acute stage. 1 did not see her during
life, but witnessed the post-mortem examination.
Autopsy. The pericardium contained several ounces of serum, and
thin patches of soft, yellow lymph adhered to it in several parts.
The mitral valve was opake and greatly thickened, the chordae ten-
dinese thickened and contracted, and the orifice only admitted the
thumb. This state was from fibrous hypertrophy, and of a date an-
terior to the last acute and fatal attack; though the redness of the
lining membrane over the whole interior of the ventricle and on the
valves, evinced that it had participated in the recent acute endocar-
ditis. The tricuspid valve was the object of greatest interest. It
was overspread with thick lumps of recent, pasty, yellow lymph,
which matted together the serrations of its margins and the chordae
tendineae, so as to contract the aperture to the size of a finger. The
interior of the ventricle and the surface of the valves were univer-
sally red, from the acute inflammation.
Remarks. This case presents the most complete instance that I
have ever witnessed of a deposition of perfectly recent lymph lead-
ing to great disease of the valve, and it is the more remarkable as
having occurred on the right side of the heart, where valvular dis-
ease is comparatively rare. Nature is, as it were, surprised, in the
midst of her process. It is clear that, if the agglutinating process
can proceed to such an extent in so short a time, the treatment for
endocarditis cannot be too prompt and decided. The rapidity with
which organization of lymph takes place, is well known; and if tem-
porizing or inefficient treatment leave time for this process, the mis-
chief is irreparable.
The following is an instance of rheumatic endopericarditis, in
which the treatment failed to arrest the inflammation in sufficient
time to prevent incurable valvular disease.
Acute Endopericarditis; contraction of the aortic valves and
regurgitation, each occasioning a murmur; adhesion of the pe-
ricardium.— William Harrison, set. 22, at St. George's, August
11, 1830. Had extremely acute rheumatism with pain in the car-
diac region, violent palpitation, and a strong Jerking pulse of 110.
Was repeatedly bled and took calomel and opium with temporary
relief; but the pain in the heart became very intense, lancinating to
the back, and being increased by inspiration: the pulse became fal-
tering, and the anxiety and distress excessive." In this state he was
relieved by a blister and the supervention of ptyalism. A fortnight
after admission, the pulse was extremely jerking, but regular; the
impulse of the heart was a violent smart, bounding blow, strongest
CASES. 521
at the left mamma: the first sound was a prolonged but not very
loud bellows-murmur. The second was like a sigh made with the
lips nearly closed. A month after this time, the impulse was strug-
gling and strong, but not lower down than natural, though the heart
was enlarged. The bellows-sounds as before, but the first louder.
Pulse 100, extremely jerking.
Remarks. — This was a well-characterized case of acute endoperi-
carditis. Much liquid effusion was indicated by the supervention
of a faltering pulse, with excessive anxiety and distress. After the
absorption of the liquid, contraction and permanent patency of the
aortic valves were indicated by the double murmur, and the latter
by the extremely jerking pulse. Adhesion of the pericardium took
place, and was indicated by the strong and struggling impulse.
The following case exhibits the same disease as the preceding, five
years after its formation.
Adhesion of the pericardium; hypertrophy with dilatation;
disease of the aortic valves with obstruction and also regurgita-
tion, and a murmur from each; contraction of the aorta, with
roughness; anaemia; the cause, rheumatic endopericarditis. —
Joseph May, aet. 20, at St. George's, under Dr. Hewctt, September
2, 1831, green-grocer, and goes about much with heavy loads. Com-
plexion lcuco-phlegmatic from much puffy infiltration. Violent ac-
tion of the heart, visible over the whole anterior chest, with a sense
of universal throbbing, especially in the temples and vertex: action
irregular: sometimes three or four unusually violent beats, occasion-
ing vertigo and stupefaction, which caused him to sink down in a
state of unconsciousness for a few seconds. Dyspnoea, greatly exas-
perated by any effort; until within a month, it occurred, with palpi-
tation, in a violent paroxysm every night, compelling him to rise,
and lasting twenty minutes. It was always accompanied by pain in
the region of the liver. An ounce of gin, which extricated flatus
by eructation, never failed to relieve both the pain, the palpitation,
and the dyspnoea. The attack invariably ended in a drenching per-
spiration and a lax dejection, followed by sleep. Had been subject
to it nightly for upwards of four years, the time of its supervention
being, at first, eight o'clock p. m. and becoming gradually later till it
arrived at two o'clock a. in. Frightful dreams; universal dropsy;
urine scanty and high-coloured; pulse rather large, extremely jerk-
ing and sharp, incompressible, irregular and intermittent.
Five years ago, had two or three attacks of acute rheumatism at
intervals of two or three months, which left pain and palpitation of
the heart. Six weeks ago, nine quarts of serum were drawn off by
punctures, with great relief.
•Auscultation. — -Impulse is double, forwards and backwards, with
the first and the second sounds respectively, which occasions a tu-
multuous jogging motion — strongest at the left mamma.
Sounds. — Both have a prolonged filing-murmur, almost continu-
ous, and loudest over the left ventricle, the first being the more hiss-
35*
522 HOPE ON DISEASES OP THE HEART.
ing. Over the right ventricle the murmurs seem remote, while the
flapping of the second sound is loud.
Above the clavicles, especially the right, strong impulse, tremor,
and a loud, hoarse murmur. The latter is heard of a more hissing,
superficial nature along the sternum in the tract of the aorta.
Diagnosis. — Hypertrophy with dilatation of the heart, the former
predominating in the left ventricle, and the latter in the right: dis-
ease of the valves on the left side; and of the interior of the aorta,
with dilatation. Adhesion of the pericardium.
After being greatly benefited by the judicious treatment of Dr.
Hewett, he was seized with erythema of the leg, from the excite-
ment of which he sank, with stupor, in four days.
Autopsy.— Heart had forced the left lung upwards to between the
fourth and fifth rib, and five or six bands, half an inch long, united
the pericardium to the costal pleura.
Pericardium adhered universally and closely to the heart. Left
ventricle: walls, an inch thick: cavity, size of an ordinary orange.
Right ventricle: not thickened; dilated to double; columnse carneae
enlarged. Auricles natural. Mitral valve thickened and opake, but
not contracted or patescent.
Aortic valves. — On one was a calcareous concretion as large as a
small pea, projecting conically in the centre of the artery: on ano-
ther was a similar but very small deposition. The two aortic valves
on the left were thickened and opake, but free.
Aorta was contracted and puckered by steatoma opposite to the
left carotid, where its circumference was only two inches and a half,
decreasing beyond that point.
Remarks. — The jogging action and the history of previous pe-
ricarditis indicated adhesion of the pericardium, and this caused the
heart to beat higher than is usual when it is greatly enlarged. The
increased impulse and extent of its range, indicated hypertrophy
with dilatation. The osseous concretions on the aortic valves occa-
sioned the loud hissing of the first sound: the prolonged murmur of
the second proceeded from aortic regurgitation, which was also indi-
cated by the extremely jerking pulse. The murmur and tremor
above the clavicles was occasioned by the steatomatous and puckered
condition of the aorta; by the unfilled state of the arteries, resulting
not only from the aortic regurgitation, but also from marked angcmia;
and by the force and velocity with which the blood was propelled,
as denoted by the extremely jerking pulse. These phenomena are
fully explained in the section on purring tremor, p. 141. The im-
pulse above the right clavicle was occasioned by the same causes, the
effect of which was probably aided by the contraction of the aorta
immediately beyond. This unusual combination of circumstances
led me to suspect dilatation of the aorta, whi.ch did not exist; but
the roughness of the vessel was correctly inferred from the loud,
hoarse murmur above the clavicles, inorganic murmurs never being
loud and hoarse.
cases. 523
The regularity of the nightly paroxysms of asthma, the good ef-
fects of gin, the termination of each attack by perspiration and purging,
the enormous discharge of serum by punctures, and the fatal conse-
quences of a slight inflammatory affection, are worthy of remark.
I could not learn that the periodicity of the attacks was connected
with malaria.
In the following case, the same organic lesions as in the preceding,
and also resulting from endopericarditis, were farther attended with
aneurism of the aorta.
Endopericarditis: aneurism of the aorta causing depression of two aortic
valves and regurgitation: mitral regurgitation: adhesion of the pericar-
dium: hypertrophy with dilatation. — Charles Williams, aet. about 25, in
St. George's Hospital, Oct. 23, 1834; butcher, formerly so strong
that he could carry 48 stone (672 lbs.) of meat fifty yards, and never
hesitated to lift and carry anything less. About four years and a
half before his admission into the hospital, he had been affected with
a " violent inflammation of the chest," (Endopericarditis?) subsequent
to which he occasionally experienced great" throbbing of the heart,"
headache, and embarrassed breathing on making any exertion.
(Valvular disease, &c. from the endopericarditis ?) About nine
months before his admission, while digging hard clay land, lie speedily
became affected with sickness, vomiting of frothy phlegm, and a
little shortness of breath, which symptoms increased through the
whole day. Next day, thirst; lifted a heavy man up stairs, which
was immediately followed by a flush succeeded by cold perspiration,
debility, and " nervousness. " Went to bed. Next day, did not
work. On the following day, before rising, was seized with vomiting,
purging, and confusion of head. He was now visited by Mr. Cot-
tingham of Bexley, who subsequently sent the man to me, and to
whom I am indebted for the following particulars. "I found him in
a state of suffering, which I thought would soon terminate his exist-
ence. He lay recumbent; slightly delirious; countenance pallid, ex-
hibiting great anxiety; skin rather cold; respiration laborious; some
cough, and frothy expectoration slightly tinged with blood: com-
plained of violent throbbing pain in the head, and of excruciating
pain in the regions of the clavicle, scapula, and humerus: his pulse
was very irregular, being sometimes full, accelerated, and intermit-
tent in the greatest degree; and at other times, (perhaps after the
lapse of a few minutes only), it was small, almost indistinct, and in-
termittent. The impulse of the heart was excessively strong, and
perceptible over two-thirds of the chest. A very distinct, loud
bellows-sound was audible over the region of the left ventricle."
(Recurrence of endopericarditis?)
"Blood was now taken from the arm, which gave temporary relief;
and, in the course of six weeks, about two hundred ounces were
drawn. It was not very tough in its texture, but exhibited the thick-
est coat of buff that I ever saw. The crassamentum at first predomi-
nated over the serum; was cupped: after 150 ounces had been drawn,
the serum appeared in excess, and, of course, our depletion was dimi-
524 HOPE ON DISEASES OF THE HEART.
nished. His diet was solely vegetable, and small in quantity. The
bowels were kept freely open. He took tartar emetic, digitalis, to-
bacco,' colchicum, and his chest was anointed with mercury and
iodine. He got daily surprisingly better."
About seven months subsequent to Ihis attack, he felt worse; Mr.
Cottingham sent him for my opinion, and I procured his admission
into St. George's Hospital.
I found him to present, in a severe form, all the ordinary general
symptoms of organic disease of the heart, which need not be de-
tailed. The physical signs were as follow.
Prominence, in a slight degree, of the prgecordial region. Dul-
ness on percussion extensive, (3% inches in diameter), yet not preter-
naturally low down. (Heart bound up by adhesion of thepericardium?)
Impulse is felt during the diastole, i. e. with the second sound,
and is strong and jogging. (This caused some to mistake it for the
systolic impulse, which was the weaker of the two.) The systolic
impulse is attended with retraction of the costal interspace next below
the nipple, as if the apex were bound down by adhesion of the peri-
cardium, and thus prevented from tilting outwards.
Sounds. — A brief sawing murmur supersedes the first sound over
the semilunar valves, and is louder and more superficial there than
half way down the heart (aortic obstruction). The second sound
over the semilunar valves is a loud flap, drawn out into a prolonged
sawing murmur, which is very loud and superficial, and continues on
ascending the aorta, but becomes rather less loud and superficial, as
if more remote. It also becomes less superficial on descending down
the tract of the left ventricle, and, near the apex, is feeble and remote
(aortic regurgitation). Near the apex also, is a murmur which super-
sedesthe first sound : it is distinct, long, and predominant, and decreases
on ascending the tract of the left ventricle (mitral regurgitation).
Purring tremor above the sternal ends of both clavicles: also, a
hoarse, abrupt, rasping sound (disease of the arch of the aorta).
Pulse 90, a jerk, with the slightest vibration, and very compres-
sible (aortic regurgitation). It intermits occasionally.
Diagnosis. — Roughness of the aortic valves or ascending aorta:
regurgitation out of the aorta, through the valves or an aneurism, into
the left ventricle: mitral regurgitation: adhesion of the pericardium:
hypertrophy with dilatation.
The patient died in January 1839, and Mr. Cottingham, to whom
I transmitted my diagnosis of aortic regurgitation and aneurism, &c.
made an examination, and obligingly sent me the preparation.
•Autopsy. — Pericardium perfectly adherent throughout its entire
surface to an enormously enlarged heart, equalling in size that of a
small ox. Ventricles. The walls of the right were about half an
inch thick, and the cavity as large as a turkey-egg. The walls of
the left were about three quarters of an inch thick, and the cavity
equal to the largest orange. Valves. The right were healthy, but
strong. The layers of the mitral were thickened, opake, and rather
contracted, but the aperture admitted three fingers. The column.®
cases. 525
carneae were pointed, as if from being drawn out, in consequence of
the immense size of the ventricle rendering them too short to close
the valve — a state tantamount in its effect to shortening of the chorda?
tendineee, regurgitation being in both cases the result. Jlortic valves
and aneurism. These are delineated in fig. 13. An aneurism as
large as a bantam's egg (a) was situated immediately above the junc-
tion of two valves, which it had depressed, and caused fibro-carti-
laginous thickening and evertion of their edges {b and c) ; by which,
and the contracted state of the third valve (d), free regurgitation was
permitted. Steatomatous disease (e e) surrounded the aneurism.
The arch of the aorta was not examined.
Remarks. — The diagnosis of this complex case was verified in
every particular with a precision, which is unattainable except by
the aid of auscultation. There was no certain evidence of the aneu-
rism, but I conjectured it from the circumstance that the patient had
twice become faint and sick during great muscular exertion (see
p. 201-2): viz. first, when digging, and, on the following day, when
lifting a person up stairs. It was probably at this time that the aorta,
perhaps diseased by the inflammation three years previously, burst
and gave origin at once to the aneurism and the second attack of
endopericarditis.
The several murmurs verify the rules which have been offered in
this work for the detection of the respective valvular diseases.
The jogging impulse, the highly seated dulness on percussion, and
the prominence of the praecordial region, verify the rules given at p.
199 for the detection of adhesion of the pericardium.
The next case beautifully exemplifies the prolongation of an aortic
regurgitant murmur through intermissions of the heart's beats.
Jlortic regurgitation; its murmur prolonged through inter-
missions of the hearts beats; hypertrophy with dilatation. —
W ., Esq., est. 60, consulted me on March 1, 1838. Palpitation
on ascending; often vertigo, especially when the stomach is empty ;
occasionally headache, especially in the right occipital region, — but
not so bad as before an attack of hemiplegia two years ago. Occa-
sionally, pain in the heart, running down the inside of the left arm.
Left leg and arm rather colder and weaker than natural, with dimi-
nished sensation. The coldness seems to increase on taking exercise,
though the body in general be heated. Left pulse rather weaker.
Slightly trails the leg, but can walk several miles. Intellect, he says,
not impaired; bowels regular; urine free, but nitre with cream of
tartar and sugar aa ^i ex n. cause copious diuresis, and relieve a dry-
ness of the tongue, which he calls fever. Pulse very large andstrong,
and slightly jerking. Digestion and general health good. Has
taken much exercise up to the present time, his physician not having
interdicted it. The paralysis two years ago followed much walking
up hill in Clifton. Percussion. Dulness over a diameter of three
inches, and seated low down. Impulse strong and heaving, with
diastolic impulse. Sounds. First, dull over the left ventricle,
526 HOPE ON DISEASES OF THE HEART.
Second, was a soft and very prolonged murmur, on the key of awe,
whispered by inspiration; it was very audible not only up the course
of the aorta, (though not of the pulmonary artery), but down the
middle of the left ventricle; and, when the heart intermitted, the
murmur continued beautifully during the whole of the intermis-
sion.
Diagnosis. — Aortic regurgitation, but not very considerable, as the
pulse is only slightly jerking: hypertrophy with dilatation.
Remarks. — The continuance of a murmur from aortic regurgitation
through the whole period of an intermission of the heart's beat, is a
circumstance sufficient of itself to convince the most skeptical, were
other evidence wanting, that the murmur could proceed from no other
source than a regurgitation out of the aorta or pulmonary artery.
The next four cases are excellent exemplifications of musical mur-
murs, and illustrate the general rules offered at p. 110—12.
Aortic regurgitation with loud musical murmur: mitral regurgitation
and murmur: hypertrophy with dilatation. — Henry JWilton, set. 28, was
admitted into St. George's Hospital, March 15, 1837. Is a carpenter:
tongue slightly furred; bowels costive; palpitation; pulse full and jerk-
ing. Six years ago, had an attack of acute rheumatism of eleven
weeks' duration, for which he had medical treatment. Two years
subsequently, had another attack. Short-winded ever since. Four-
teen months ago, first heard a peculiar noise in the chest; consulted
Dr. M'Cabe of Hastings, who pointed out to him the palpitation, of
which he was himself previously unconscious. March 9th, 1836,
went into the Brighton Hospital. Was salivated, and says he caught
cold and had another attack of acute rheumatism; was in the hospital
four months. Three weeks ago, went into St. Bartholomew's Hos-
pital, under Dr. Latham ; and, as he gave him no prospect of relief, he
came into St. George's.
Sounds. — A musical murmur with the second sound, loudest over
the semilunar valves, and thence up the aorta; while a feeble sighing
murmur may be heard accompanying and prolonging the musical note
down the ventricles, but not above the valves. The musical sound
is like the oo of coo : it swells and rises a semi-tone in the middle, like
the mew of a kitten. It is so loud as to be audible a foot from the
chest through the air, and also in the palm of the hand when the ste-
thoscope is applied to that part. I have only once heard a louder
musical murmur (aortic regurgitation). A murmur attends the first
sound below the middle of the left ventricle (mitral regurgitation).
Impulse, violent, extensive, jogging, with strong diastolic impulse. Dul-
ness on percussion, extensive and low down.
Diagnosis. — Aortic and mitral regurgitations. Hypertrophy with
dilatation; possibly, adhesion of the pericardium.
He died about three weeks after admission, from purpura haemor-
rhagica.
Autopsy. — Lungs gorged with blood, and presenting many pur-
purous extravasations. Pericardium adhered rather loosely over
about two-thirds of the heart. (The looseness of the adhesion wa§
cases. 527
the reason why the heart was not bound up in a higher situation than
natural, a circumstance which created a doubt as to the existence of
adhesion). Left ventricle rounded, and about an inch thick: its
cavity, a very little enlarged. Right ventricle, a little dilated.
Aortic valves. All were yellow and morbidly opake, from fibrous
thickening. The corner of one was torn from its origin to the extent
of two-and-a-half lines, and the flap hung back and overlapped the
ventricular side of the valve, so as to allow free regurgitation. The
flap was folded on itself, and the folds were adherent to each other,
evincing previous inflammation (see fig. 11, a). In the dependent
flap was a hole one-and-a-half lines in diameter (see fig. 10, a). Mi-
tral valve and chordae had undergone similar opake yellow fibrous
thickening, and several clusters of vegetations — one or two as large
as a pea, existed on the auricular side, a little below the margin. The
valve was contracted so as only to admit two fingers. Hence, the
regurgitation. Tricuspid valve, a little thickened. Pulmonic valves
natural.
Remarks. — The diagnosis was exactly verified. The valvular re-
gurgitations were in accordance with the rules inculcated throughout
the work for the detection of the several valvular diseases.
Contraction of the aortic valves and a musical murmur with
the first sound: regurgitation through the same valves: mitral
regurgitation with a second musical murmur. — V. . . . , aet. 50,
consulted me, April 5, 183S, in company with Mr. Eisdcll, Surgeon,
77, Sloane-street: of full habit; a publican, and a moderate, temperate
liver: has drunk gin in moderation. Subject to gout in the feet for
ten years. Has been very active, walking four miles an hour. For
three years has been short-winded on ascending: rather drowsy in
the mornings, but has no other head symptoms. Pulse small, weak,
irregular, unequal. Tongue whitish.
Impulse natural. Sounds. A musical note is heard to be loud
and near-sounding an inch below, and a little to the sternal side of
the left nipple, and it accompanies the first sound of the heart (mitral
regurgitation). It diminishes on ascending the ventricle, and, half
way up, it is almost inaudible. On ascending still higher, a second
musical note with the first sound becomes audible, and is perfectly
distinct opposite to the aortic valves, and thence two inches along the
aorta, where it sounds more superficial or near than opposite to the
valves themselves. This musical note is mixed with a common mur-
mur on a lower key than a whispered r, (apparently from the pulse
being weak,) which may also be heard along the aorta. Both the
sounds are very indistinct along the course of the pulmonary artery.
The second sound over the aortic valves is tailed by a feeble, though
distinct whispered awe murmur, which diminishes on descending
down the left ventricle, and is prolonged to the ensuing ventricular
systole.
Diagnosis. — Mitral regurgitation: contraction of the aortic valves
and regurgitation : little or no hypertrophy or dilatation.
Remarks. — This is the only case that I have seen or heard of, pre-
528 HOPE ON DISEASES OF THE HEART.
senting two musical murmurs. It is proved that there are two, by
both being almost inaudible midway between their sources; namely,
about the middle of the ventricle. This circumstance shows that a
musical sound is best propagated in the direction of the current: for
I have found such a sound, when produced by aortic regurgitation,
audible down the whole extent of the left ventricle. The pulse has
no jerk, partly because the mitral regurgitation renders it too small,
weak and irregular to have a jerk; and partly, perhaps, because if I
may judge from the weakness of the murmur, the aortic, regurgitation
is not considerable. Mr. Eisdell was present at this examination,
and verified all the facts.
Pericarditis with effusion; and endocarditis, first with mitral
regurgitation and a musical murmur: afterwards with aortic
regurgitation: an attrition-murmur on absorption of the fluid:
final adhesion of the pericardium: sound of costal percussion :
hypertrophy. — Robert Jones, set. 15, under the writer's care at St.
George's Hospital, Nov. 13, 1835. Three months before admission,
had acute rheumatism so severely as to be confined to bed for a fort-
night.
On admission there was dulness on percussion in the precordial
region over a space of three inches across by five perpendicular — the
outline being pyriform, with the smaller end ascending up the ster-
num to the second rib. Impulse increased. Sounds, A very loud,
rough murmur, with a broken whistle or creak attends the first sound,
and is loudest over the apex of the heart (mitral regurgitation). Pur-
ring tremor is felt. Palpitation; dyspnoea; moderate fever; pulse
quick.
Diagnosis. — -Chronic endopericarditis, with hydropericardium; mi-
tral regurgitation; hypertrophy.
The remedies employed were, a bleeding of §ij only; pil. hydr. till
the gums were touched; diuretics; and a succession of blisters on the
precordial region. At the end of a month, the dulness on percussion
had descended three or four inches, and there had supervened a con-
fused, continuous rumbling murmur, heard equally over the whole
heart. The previous broken whistle of the mitral valve had dege-
nerated into a less musical chirp. Less impulse; pulse slower.
Diagnosis. — Most of the fluid absorbed: a little probably churned
between layers of rough lymph on the pericardium, and occasion-
ing the continuous rumble.
The same treatment was prosecuted. In nine days more, the con-
tinuous, diffuse rumble was weaker, and the mitral chirping sound
had ceased and been replaced by a pure, loud sawing-murmur parti-
cularly loud over the apex, but obscure elsewhere. The precordial
region was protruded. Dulness still more extensive than natural.
Diagnosis. — Further absorption of fluid.
In twelve days more, a prolonged sawing-murmur began to attend
the second sound over the aortic valves, but not over the pulmonic.
Diagnosis. Aortic regurgitation.
In another week the diffuse rumble was further diminished, being
barely distinguishable from the two regurgitant murmurs.
cases. 529
Diagnosis. — Commencing adhesion of the pericardium.
At the end of the next three weeks, a new phenomenon struck my
attention: namely, though the mitral regurgitant murmur was a pure
whizz so long as the pulse was under 80, yet, when the action of the
heart was accelerated by any effort to 90 or upwards, a very loud
and distinct click was superadded to the whizz, and it gradually went
off again under the ear of the auscultator in proportion as the heart
returned to its previous tranquil pulsation.
I noticed that the click was later than the commencement of the ichizz
by a very appreciable interval. This phenomenon was verified by
Drs. Macleod, Marshall Hall, and Jefferson, and Messrs. Keate and
Peregrine. I at first imagined it to be the natural click of the mitral
valve, becoming audible when the action of the heart was violent.
But, in this case, it ought to have preceded, not followed, the com-
mencement of the whizz. I subsequently ascertained that it was
nothing more than the extrinsic sound of costal percussion, described
at p. 73, and of which other illustrative cases will presently be ofiered.
At the expiration of seven weeks more, making a total period of
four months and a half, he was dismissed in a state of good general
health, and with a pulse of 78. The continuous rumble had wholly
ceased; the two regurgitant murmurs alone were heard; the purring
tremor was no longer perceptible; the precordial region was promi-
nent; the impulse strong, and the dulness on percussion two inches
and a half across.
Diagnosis. — Adhesion of the pericardium; aortic and mitral regur-
gitation; hypertrophy.
I lost sight of him for a year and a half; when Mr. Davis, Surgeon,
informed me that he had died of dropsy, and obligingly invited me
to inspect the body. We made the following notes.
Autopsy, April 1, 1S37. — External dropsy and ascites. Pleurae
contained a quart of serum. Lungs gorged with blood, cedematous,
and rather condensed by the pressure of the fluid and heart. Heart :,
in the pericardium, very large, pushing the left lung as high up as
the fourth rib. Pericardium universally adherent, except at a small
point forming the angle between the base and the great vessels, where,
it may be remarked, the rumbling murmur had continued longest.
The false membrane forming the medium of adhesion, was of an
unhealthy character, being bloody, imperfectly organized, and, as it
were, rotten. Ventricles. Walls of the left, about seven lines thick:
of the right, three lines, — constituting hypertrophy in a small, slim
youth of aet. 17. Mitral valve of opake yellow colour, from fibrous
thickening both of the lamina? and the chordae tendineae, and con-
tracted, so as to admit the passage of two fingers only (hence the
regurgitation). Aortic valves presented fibrous thickening with
contraction and a fringe of small vegetations (hence the regurgitation).
The tricuspid and pulmonic valves were healthy. Liver gorged
with blood.
Remarks. — This case is interesting and instructive in a triple point
of view.
12— i 36 hope
530 HOPE ON DISEASES OF THE HEART.
1. It presents an instance of a musical murmur (a broken whistle)
degenerating into a loud sawing-murmur, and this was the object of
its introduction in the present situation.
2. It is an excellent example of the sound of costal percussion
(p. 73), its extrinsic origin being beautifully apparent id consequence
of the complete extinction of the natural first sound by the sawing-
murmur, and in consequence of its occurring later than the com-
mencement of the murmur.
3. The case presents a graphic exemplification of the progress and
phases of a chronic endopericarditis, and of the ease with which the
valvular may be discriminated from the pericardiac attrition-murmurs,
by the rules developed at p. 182. It might be supposed that the
transitions, in such cases, are so fine as only to be appreciable by an
adept: yet it is not so. There is a force of conviction to be derived
from hearing, which cannot be produced by description or by the
strongest asseverations, and I shall presently show, in the case of
Rogers, that this conviction may be attained by a novice.
Aortic regurgitation, with murmur ultimately becoming mu-
sical: hypertrophy with dilatation. — Joseph Tindall, set. 30, robust,
and used to lift heavy weights; labourer on the railway. Applied to
me March 26, 183S. Great palpitation and dyspnoea on any exertion,
which has disabled him from work for eleven months. Thinks he
had rheumatic fever several years ago. Pulse pre-eminently^'er^-
ing, — especially on any slight exertion. It is like a hard ball shot
with force under the finger, the artery feeling empty in the interval.
From this pulse alone, 1 guessed aortic regurgitation. Impulse,
considerably increased. Dulness over about three inches in diameter
and preternaturally low down. Sounds. A whispered awe murmur
with the second sound is heard over the aortic valves and two inches
up the aorta, where its key rises to a whispered r tone. The murmur
may be traced down the left ventricle, with a gradual diminution of
intensity and lowering of its key below the awe tone. Near the
apex it sounds feeble, remote and like a whispered who. It is weak
up the pulmonary artery. This was the nature of the murmur for
five or six weeks, at the end of which time it became musical, —
especially when the circulation was accelerated. The musical note
was clearest and most free from murmur two inches up the aorta:
opposite to the valves, the tone sounded lower and more remote, and
was mixed with a murmur: on descending down the ventricle, the
musical note became very indistinct while the murmur became
louder — which shows that the motion of the blood within the ven-
tricle occasioned murmur, while the musical note was probably gene-
rated by the edge of the valves.
D,agnosis. — Regurgitation through the aortic valves: hypertrophy
with dilatation.
The patient is still living.
Remark. — This case is a perfect exemplification of an ordinary
murmur becoming musical, and of the co-existence of the two. It
also shows that a certain force of current is requisite for the pro-
oases. 531
duction of the musical note, as it diminished when the heart became
calm, and vice versa.
The five following cases present instances of disease, with murmurs,
in the pulmonary artery, and they completely exemplify the physical
signs of these rare affections.
Great dilatation of the pulmonary artery. Hypertrophy and dilatation
of the heart. — Sarah Wetherly, aet. 36, of yellowish complexion, was
admitted into St. George's hospital under Dr. Seymour, January 20th,
1830, with dyspnoea; pain at the scrobiculus cordis; ascites, oedema
pedum; pulse 70, large, full, and rather tense; tongue clean; urine
scanty; catamenia suppressed for five months.
Short-winded for ten years, in consequence of striking her breast
against a post. Eight months ago the catamenia were checked by
cold, from which time she dates her complaint; but the oedema did
not supervene until three months afterwards, when the menstrual
flux became totally suppressed.
•Auscultation. — Resonance of the praecordial region is extensively
dull; prominence, pulsation, and purring tremor between the carti-
lages of the second and third left ribs. Impulse, much more extensive,
and considerably stronger than natural, particularly in the left prae-
cordial region. The pulsation is felt in cpigastrio. Sounds. — The
first, is an extremely loud, harsh, and superficial sawing-murmur. It
is extensively audible, but most so on the prominence between the
second and third ribs.
Diagnosis. — Hypertrophy and still more dilatation of the heart, greatest
on iiie left side. Dilatation of the origin of the aorta, probably forming
an ancurismal pouch towards the left. V. S. ad gx. — R calomel, gr. iij.
hac nocte. — H haust. sennae cum tart, potassae 31 ij eras mane. — &
haust. salin. efferv. ter die.
Died a month after admission.
Autopsy. — Heart encroached much, by its size, on the left side of
the chest. It was hypertrophous and dilated; most on the left side.
Pulmonary artery remarkably dilated. Its internal circumference
near the valves was four inches and a half; and midway between this
and the bifurcation, it was five inches. The enlargement did not
extend beyond the bifurcation. The sigmoid valves appeared to be
put on the stretch, and too small to close the orifice, yet this could
not have been the case, as there was no murmur from regurgitation.
Aorta rather contracted. Mitral valve slightly thickened. Abdo-
men contained three or four quarts of straw-coloured fluid. Liver
rather enlarged and hardened, and its peritoneum thickened by old
inflammation.
Remarks. — Part of the diagnosis, in this case, was inaccurate: but
as dilatation of the pulmonary artery is one of the rarest affections
incident to the human frame, and as its signs had not previously been
described by any author; while aneurism of the ascending aorta is an
ordinary disease with well-known signs, the former could not, on any
certain grounds, have been diagnosticated in preference to the latter.
On reviewing the signs of the former, however, they appear to me so
532 HOPE ON DISEASES OF THE HEART.
pathognomic as to render the affection easy of diagnosis for the fu-
ture. The particulars are given at p. 426, to which the reader is re-
ferred.
As the pulmonary artery is close to the surface, the sound possesses
in a peculiar degree the character of proximity to the ear of the aus-
cultator.
The strong impulse, and tenso pulse denoted the hypertrophy. The
great extent of the pulsation, the precordial dulness, and the large-
ness of the pulse, indicated the concomitant dilatation. The left side
was supposed to be more enlarged, because the impulse was strongest
over it.
The next case is another of dilatation of the pulmonary artery.
Dilatation of the 'pulmonary artery, with continuous murmur;
Hypertrophy with Dilatation. — Miss L P , set. 16, with-
out any signs of puberty, but florid and healthy-looking. Bowels
regular, tongue clear, appetite good, sleep sound, palpitation on any
exertion, especially ascending, or on fright. When lying, has some-
times a bound of the heart, which makes her start up, and is followed
by faintness. Slight pain down the left arm. Has also a considerable
curvature of the spine.
When an infant, was pale and unhealthy-looking, and has always
been delicate. Hands occasionally "go dead." No cyanosis.
•Auscultation. — Left precordial region slightly prominent, and a
bend in the cartilages of the ribs. Impulse increased: its heaving
and back-stroke may be seen as well as felt. The impulse is high,
and extends towards the middle of the sternum, as if the right ven-
tricle were its seat, but the left ventricle is also affected, as the pulse
is rather larger and stronger than natural, and the carotids throb.
Sounds. — Between the cartilages of the second and third left rib,
an exceedingly loud and superficial sawing-murmur accompanies the
first sound, and confuses the second. It decreases downwards, and,
on the body of the ventricles, sounds remote. It follows the ramifi-
cation of the pulmonary artery to the left, but it is almost inaudible
above the clavicles (hence not seated in the aorta). The second sound
is audible through the murmur. Purring tremor in an intense degree,
and impulse, are felt between the cartilages of the second and third
left ribs, but not above the clavicles (hence, not dilatation of the aorta).
Diagnosis. — Dilatation of the pulmonary artery, probably congenital:
hypertrophy with dilatation of both ventriclej.
Remarks. — The situation of the murmur between the second and
third left ribs restrict it to the pulmonary artery rather than to the
aorta, and the impulse and tremor denote dilatation of the vessel itself
rather than a mere contraction of the pulmonic valves or orifice.
Still, it is impossible to say that the latter also does not exist, as the
murmur of the artery absorbs any that might proceed from the valves:
it is probable, indeed, that it does exist, because the disease appears
to have been congenital, and when this is the case there is, in the
great majority, a contraction of the pulmonic orifice and a communi-
cation between the two sides of the heart, even though there be no
cases. 533
cyanosis. The only point in which this case differs from the pre-
ceding, is, in the continuity of the murmur.
I have, in two subsequent cases of supposed dilatation of the pul-
monary artery, found the murmur continuous. Not having had the
opportunity of autopsy, I cannot speak positively respecting the cause,
but 1 have reason to suspect that it is a venous murmur, seated in the
vena innominata, and adding its continuous sound to the murmur of
the pulmonary artery. It will be asked why a dilatation of the pul-
monary artery should create a murmur in the vena innominata; see-
ing, as may be done by reference to the frontispiece, Fig. 1, that the
vein in question, (k) is separated from the pulmonary artery (m) by
the interposed aorta (7). There is difficulty in answering this question.
The case of Phoebe James, described at p. 134, may perhaps throw
some light upon it. In this case, the vena innominata was put upon
the stretch, and thus rendered more susceptible of vibration, and of
the sonorous effect of accidental indentations on it by parts which it
crosses. Can dilatation of the pulmonary artery, by displacing con-
tiguous parts, as the aorta, indirectly act in the same way? Or, after
all, is the venous murmur of the innominata without mechanical
cause, and an accidental adjunct to the dilatation of the pulmonary
artery? I have certainly heard it in anemic subjects presenting it
also in the neck, wholly independent of disease in the pulmonary
vessel.
Jinaimia; contraction of the pulmonary orifice with murmur and thrill.
-~Grace Bowden, aet. 16, under the care of the writer, at St. George's
Hospital, January 30, 1S39. Pallor; palpitation; breathlessness; faint-
ness; weariness; throbbing in the head; aching in the back; pulse quick,
jerking; tongue clean; anorexia; bowels constipated; calamenia have
not appeared; leucorrhaea six months. Drooping for a year.
Auscultation. — Loud venous murmur in the internal jugulars. An
exceedingly loud murmur with the tirst sound in the pulmonary
orifice and along the pulmonary artery, but weaker along the aorta:
louder down the course of the right ventricle, than of the left. A
Strong thrill between the cartilages of the second and third left ribs.
Diagnosis. — Aneemia: contraction of the pulmonary orifice. (Con--
fect. Ferri 3i t. d. s. — pil. aloes cum, myrr. i. vel ij. o. n. Animal
food twice a day.)
Remarks. — Here, the disease was seated in the pulmonary orifice
rather than in the course of the vessel, because the murmur was
loudest immediately over the valves, and because there was no im-
pulse between the cartilages of the second and third left ribs. One
of the principal objects for the introduction of the present case, was,
to show that the sound was transmitted more loudly down the course
of the right ventricle, than of the left — the converse of what obtains
when the aortic orifice is the seat of contraction. The same will be
noticed in the next case (Rogers), who had pulmonic regurgitation
as well as contraction. The establishment of this fact was necessary
to complete the scheme of valvular diagnosis broached in this work.
It must, further, be noticed that a contraction of the pulmonic
36*
534 HOPE ON DISEASES OF THE HEART.
orifice, by breaking the stream, suffices to create a thrill between the
cartilages of the second and third left ribs, but not impulse.
The general symptoms, including the jerking pulse, were mainly
dependent on the anaemia. They greatly subsided with the removal
of that condition in six weeks. The venous murmur ceased.
Softening and ossification of the pulmonary artery, with murmur. —
Lady R. aet. about 60. I attended this patient in 1853 or 1834, in
consultation with Mr. Cottingham of Bexley. Having lost my notes
of the case, I shall merely state that she presented the ordinary
symptoms of organic disease of the heart, and experienced such a
craving for breath, as to sleep, even during winter, with her window
open. There was a murmur over the semilunar valves.
Mr. Cottingham favoured me with the following particulars of the
examination:
Jlutopsy. — The right auricle and ventricle were much dilated and
attenuated. The pulmonary artery, where it crossed the aorta, pre-
sented a circumscribed spot as large as a shilling, of a darker hue than
the rest of the vessel, and slight friction between the finger and thumb
abraded it into a hole. It seemed almost pulpy. Where the pul-
monary artery plunged into the lungs, it was found quite ossified, as
well as the larger bronchial tubes.
Remarks. — This is the only instance that has occurred to me of
ossification of the pulmonary artery. Its condition was the cause of
the murmur, and probably of the unusual degree of craving for breath
experienced by the patient.
Jlcute endopericardilis; double pulmonic murmur, from contraction and
regurgitation; attrition-murmur, suspended by liquid effusion, and re-estab-
lished on its absorption. — Edmond Rogers, set, 29, was admitted as an
out-patient of St. George's Hospital, under the writer's care, March
20, 1839. Eight years previously he had been affected with acute
rheumatism, and had been short-winded and delicate ever since.
Three weeks before admission, had been "taken worse," and affected
with a pain in the region of the heart, but during the last week it had
been confined to the epigastrium, where it was extensively diffused.
At the time of his admission he was pale and emaciated; pulse 80,
weak, not jerking; bowels constipated.
Impulse natural. Sounds. — A loud, superficial, r murmur with the
first sound, and a more prolonged awe murmur with the second, were
heard over the pulmonic valves, and were louder along the whole
tract of the pulmonary artery and right ventricle than along that of
the aorta and left ventricle. The first murmur was propagated more
loudly up the pulmonary artery, and the second, down the right ven-
tricle, the focus of each being, the pulmonic valves. A purring tremor
was felt between the cartilages of the second and third left ribs, with
both murmurs, but was stronger with the first.
Being unable positively to determine whether the pain in the epi-
gastric, and previously in the precordial region, was inflammatory, or
merely angina connected with previous organic disease, and aggra-
vated, perhaps, by the constipation, I ordered a purgative, and a
cases. 535
belladonna plaster over the region of the heart, and requested him to
call again at a short interval. He did not return till the fifth day.
Though the constipation had been removed, the diffused epigastric
pain remained: there was much anxiety of countenance, pallor, weak
pulse, suspirious respiration, and increased dulness on percussion of
the precordial region.
Sounds. — An attrition-murmur of a croaking character or like
tearing calico, with a purring tremor, was now discovered over the
whole inferior part of the heart, especially on the left side. This
was heard by several gentlemen, some of whom could vouch for its
absence at his previous visit. No signs, general or physical, of
pleurisy. The existence of acute pericarditis was therefore demon-
strated, and 1 inferred that the pain which had existed for three weeks,
and probably the pulmonary murmurs, were also results of inflamma-
tion. I induced him to remain in the hospital, and prescribed as fol-
lows on the 25th.
R Ilydr. chlorid gr. vi. opii extr. gr. i. Mft. pil. ter die sumendus
— R Ung- Hydrarg. fort 3i, axillae utrique omni mane et vespere affri-
candam. Empl. Lytte cordis regioni applicetur, et postea cataplasma
assidue adhibeatur.
As he was cold and exhausted, I postponed blood-letting. He now
passed into the hands of the physician for the week.
27th. The mercury was omitted at one o'clock, as the gums were
slightly sore; and he was bled to 3xii: blood, buffed and cupped.
28. I found him much worse. He lay diagonally, inclined to the
right side; respirations 80 per minute, with dilatation of the alae nasi:
pulse 120, weak and intermittent: increased anxiety: pain less acute,
but more diffused over the lower partof the precordial region : atlrition-
murmur and tremor gone! first sound very obscure at the apex: dulness
more extensive: pulmonic murmurs continue.
Diagnosis. — Liquid effusion within the pericardium has increased,
and the layers of the membrane are separated.
29. Gums sorer: better: namely, respiration freer; less anxiety; pulse
112, rather sharp; less pain and oppression in the pnecordia; dulness
diminished: but still no attrition-murmur, and first sound still weak
and remote: pulmonic murmurs as before.
Diagnosis. — Effusion diminishing (in connexion with the full action
of mercury.)
31. Still better: namely, pulse 96, regular, and its sharpness gone;
respiration freer; further diminution of the precordial soreness, and
dulness on percussion. The attrition-murmur has returned, and is
now very loud, and singularly superficial or near-sounding, over the
whole heart. It is double, and the first half, or that corresponding
with the pulse, is the louder and longer. It resembles the rubbing
together of two dry hands, and is unequally rough. It is so loud as to be
audible, not only over the whole anterior chest, but even on the ab-
domen— an observation which verifies the remarks made at p. 177.
The pulmonic murmurs are obscurely audible through it.
Diagnosis. — Liquid effusion gone, and there is attrition of dryish
lymph.
536 HOPE ON DISEASES OF THE HEART.
April 1. Feels better; pulse 100, rather unequal in speed, and there
are occasional intermissions; respiration free, but easily accelerated:
attrition-murmur is rather diminished, and it has a triple or broken
character: the pulmonic murmurs can now be distinctly heard
through it.
5. Attrition-murmurs now quite gone; pulmonic loud and distinct.
The regurgitant murmur, indeed, has become louder than ever, and
the tremor attending it is stronger than that with the direct murmur.
The patient was dismissed in a week or ten days, and said to be
convalescent.
Remarks. — A number of practitioners and students carefully
watched the several transitions of this case; and even those who had
not before witnessed a similar affection, declared the physical phe-
nomena to be so distinct, as to create a conviction in their minds
which was irresistible. All could with perfect ease discriminate the
pulmonic, from the attrition-murmurs, partly by the rules of situation
explained at p. 182, and partly by the total difference in character of
the two classes of murmurs. All were equally pleased to observe
the beautiful correspondence between the general and the physical
signs — the former assuming their worst type (on the 28th) when the
cessation of the attrition-murmur, &c, indicated much liquid effusion
in the pericardium; while, on the other hand, they improved in the
same proportion as the physical signs denoted the gradual absorption
of the liquid. Without auscultation, such cases are, and always have
been considered, darkness and confusion. The happy effects of mer-
cury, to which the patient owed his life, were strikingly evinced by
the remedy coming into full operation, and affording immediate
relief, at the critical moment (the 28th) when experience has shown
that other remedies are almost unavailing.
The case presents two circumstances of especial interest: 1. a pul-
monic regurgitation, which is exceedingly rare; and, 2, a tremor
attending that regurgitation.
We now leave the diseases of the pulmonary artery, and pass to
the sound of costal percussion and metallic tinnitus described at p. 41.
The following cases, in addition to that of Jones, p. 506, are examples
of this phenomenon.
Carrington consulted me March 30, 1838; set. 30, tall, thin, a
footman, has hypertrophy, with palpitation and dyspnoea on exertion.
There is pretty strong impulse between the fifth and sixth left ribs,
where the apex impinges. On placing the stethoscope immediately
over this spot, a metallic tinnitus (the cliquetis of Laennec) was
heard, exactly like that produced by tapping the back of the hand
with a finger while the palm covers the ear. The first sound of the
heart seemed to be double, like that produced by tapping a table with
two fingers at once, but one rather higher than the other: the second
of the two sounds was the tinnitus. I have for many years noticed
this double sound without tinnitus.
I made the following series of observations on the phenomenon.
1. The tinnitus ceased and the sound was single when either the
cases. 537
upper or lower edge of the stethoscope was pressed obliquely into
the intercostal space.
2. The tinnitus ceased, but the sound continued double, when the
stethoscope with the stopper in was applied flatly over the ribs.
3. I filled the hollow cone with cotton wadding, which, by its
elasticity, pressed the intercostal space inwards: when the tinnitus
ceased and the sound was single.
4. When 1 withdrew half the wadding, and left the cone only
lightly filled, the double sound and tinnitus returned, though rather
diminished.
5. The tinnitus continued, but rather duller, when I placed a penny
flat across the two ribs, and listened with the stethoscope upon it
6. It ceased, as well as the double sound, on full inspiration, and
was always strongest during expiration.
7. It was increased by leaning forward during expiration.
Conclusions. The tinnitus cannot proceed from the heart impinging
against the chest after having been withdrawn from it, because it
was loudest in obs. 7, viz. while leaning forward during expiration —
a posture which keeps the heart in constant opposition with the walls
of the chest, as may be proved by dulness on percussion.
I infer that the tinnitus and second half of the double first sound
proceed from the apex of the heart sliding upwards (as it may be
seen to do in the poisoned ass) and impinging against the inferior
margin of the fifth rib; for, whenever the intercostal space was
pushed in, as in obs. 1 and 3, so as to prevent the edge of the rib
from being prominent, the tinnitus and double sound ceased.
I infer that the tinnitus itself proceeds simply from reverberation
of sound within the cone of the stethoscope; because it ceased, yet
the sound remained double, when the stopper was employed (obs. 2);
and because it existed, but with diminished intensity, when the cone
was lightly filled with cotton (obs. 4), and also when a penny was
interposed between the chest and the open cone (obs. 5) — both of
these arrangements admitting of slight reverberation of sound within
the cone.
Assuming these explanations to be correct, it would follow that
the sound of costal percussion and the attendant tinnitus should be
less apt to occur in stout and plethoric subjects: because in such, the
intercostal spaces are fuller, and the edge of the fifth rib therefore
less prominent. Now, all the instances in which I have met with
tinnitus, since my attention has been turned to the subject, have
been in the persons of thin individuals. Thus, the present patient
was thin: Robert Jones (p. 506) was emaciated: so also were the
subjects of the two following cases, and several others, of whom the
notes lie before me.
The next case shows more distinctly than the preceding the ooik
stitutional circumstances under which the sound of costal percussion
and tinnitus occur.
Sound of costal percussion with tinnitus subsiding on the reduction of
anozmia. — A . . . n} consulted me April 9, 1838. J&t. 30; emaci-
538 HOPE ON DISEASES OF THE HEART.
ated; pale; very nervous from youth; violent palpitation, increased
by exertion and mental emotion; pulse 100 to 120, small and weak;
languor; lassitude, &c.
Impulse increased. Sounds. Both loud; the first was double, and
a tinnitus attended the second half. It was restricted to the space of
an inch, where the apex beat. It ceased on pressing the edge of the
stethoscope into the intercostal space: also on putting a penny over
the spot and listening upon it; but, in the latter case, though the tin-
nitus ceased, the double sound remained. The same occurred when
the stopper was used.
Diagnosis. Anaemic and nervous palpitation. (Sedatives, iron,
aloes, and animal diet.)
A fortnight after the preceding report, the anaemic symptoms and
nervous excitability had considerably abated, the impulse was less
abrupt, the double nature of the first sound had diminished, and the
tinnitus had become so much less distinct as not to be very well
characterized.
At the expiration of nine months, when the patient, though thin,
had recovered from his anaemia and excitability, the first sound was
single when the circulation was calm, and it was only during accele-
rated action of the heart that a slight degree of tinnitus was per-
ceptible.
Remarks. — From this and other cases it appears to be deducible
that the diminution of anaemia, by rendering the impulse of the
heart less sudden, diminishes the smartness with which its apex glides
up against the edge of the fifth rib, and thus diminishes the tinnitus.
If this first be found true and general, it follows that anaemia will be
one of the elements contributing to the production of tinnitus, pal-
pitation being a second, and meagreness a third.
The following case shows that tinnitus is not confined to the heart.
Tinnitus of the subclavian. — Dr. A r, set. 50, exceedingly
emaciated; hypertrophy with dilatation; pulse 90 to 130, singularly
jerking, yet no aortic regurgitation (anaemia). He had most distinct
tinnitus produced by the subclavian artery impinging against the
clavicle, little cellular or adipose tissue being interposed to intercept
the blow.
Remarks. — When we reflect on the slightness of the tap on the
back of the hand, which suffices to produce tinnitus when the palm
is applied to the ear, we shall easily understand that the blow of an
artery against a bone or of the apex against the fifth rib, may be
adequate to the production of the phenomenon.
The two following cases are instances of the venous thrill, re-
specting the existence of which I expressed a doubt at p. 136. I
met with the cases while the work was passing through the press,
and when it was too late to cancel the passage referred to. I found
that I had previously failed to notice the phenomenon in consequence
of employing too much pressure. The thrill is so delicate, that
anything more than mere contact of the pulp of the finger with the
•kk), renders it imperceptible.
cases. 539
Venous thrill— Sarah Pike, set. 28; at St. George's, April 10, 1839.
Extremely pallid; constipation; catamenia suppressed for four months;
all the other symptoms of anaemia in the highest degree.
Messrs. F. Browne and H. Daniels, students of St. George's, ve-
rified the venous thrill, and, at my request, made the following notes.
"Loud venous murmur of the internal jugular vein, and a thrill
may be felt at its lower part by placing the linger with extreme
lightness over the vein. It is most perceptible during inspiration/'
Three weeks later, the thrill was gone and the venous murmur
diminished, in consequence of the anaemia having been considerably
reduced.
Miss JV. . . c presented the same thrill under identical circum-
stances, except that the anaemia was less considerable.
I am at a loss to decide whether the continuous murmur the in
following case was arterial or venous.
Disease of the femoral artery and continuous murmur icith augmenta-
tion.— John Allen, aet. 47, in the St. Mary-le-bone Infirmary, under
the care of my former colleague Mr. Perry, had a dilatation of the
femoral artery, extending from within two inches of Poupart's liga-
ment to the popliteal region. Along its whole course, there was a
strong thrill and a remarkably loud murmur, which continued without
intermission, though louder during the arterial pulsations. On dissec-
tion, the artery was found to be nearly as large as the abdominal
aorta, and its coats not only fragile, but so thin as to resemble a vein
rather than an artery.
Remarks. — On the first view of this case, the murmur would be
ascribed solely to the state of the artery; but I suspect that the con-
tinuous part of it was venous, in consequence of the vein being com-
pressed by the enlarged artery.
Aneurism in the substance of the left auriculo-ventricular septum; dis-
ease of the aortic valves, probably with regurgitation; dilatation of the
heart. — James Brown, vet. 27, a tailor; complexion cadaverously pale,
admitted into St. George's Hospital under Dr. Chambers, Dec. 9,
1829. Palpitation; vehement impulse; throbbing of the carotids;
tedema pedum; dysentery; pulse 130, full, strong and jerking.
Is a drinker. Has been short-winded for a year at least, and disa-
bled for three months. Died Jan. 15, 1S30.
Autopsy. — Left ventricle dilated, but the parietes of natural thick-
ness. Aortic valves. Their bases in parts detached by steatomatous
disease. Beneath the valve nearest to the left auricle, the little fin-
ger could be introduced and insinuated under the lining membrane
of the heart to the extent of half an inch, when it emerged through
a rugged, steatomatous opening into the cavity of the vrntricle.
From this canal, a second extended transversely to the left, into the
muscular substance of the septum between the auricle and ventricle;
and here it formed a pouch about as large as a nut, which bulged up-
wards and backwards, behind the pulmonary artery.
Remarks. — This case presents an instance of real aneurism, that
is, partial dilatation, of the heart. Its physical signs are a desideratum.
540 HOPE ON DISEASES OF THE HEART.
I did not see the patient before death, and therefore had not an op-
portunity of noticing them. The detached state of the aortic valves,
put in' connexion with the jerking pulse, renders it almost certain
that there was a murmur from regurgitation. This, however, is not
a sign of the aneurism in particular.
The two following highly interesting cases were sent to me by my
friend Dr. Lombard, an eminent Genevese physician, educated in
England, and in great estimation amongst the English residents at
Geneva.
Hypertrophy and dilatation; universal adhesion of the pericardium, with
double impulse. Tubercles of lungs, pleura, pericardium, heart, bronchial
glands and peritoneum. — A Genevese, set. 8, had for several months ex-
perienced frequent paroxysms of cough and become very emaciated
and feeble. When visited, the symptoms were, extreme emaciation;
frequent cough; easy expectoration of stringy mucus with yellowish
puriform flakes; excessive palpitation; pulse very frequent.
Physical Signs. — Impulse. The ear is raised by the beats of the
heart, which are tumultuous and of great energy.
Lungs. — Resonance of the left side in front almost flat; rather ob-
scure behind: very clear on the right side. Mucous rale in some
parts, especially on the right, where respiration is puerile. On the
left, absence of respiration in the greater part of the lungs.
In two months he died from oppression and obstinate vomiting.
Two days before death he had suffocative dyspnoea, with the singular
phenomenon that the beats of the heart were very intense, tumul-
tuous, and twice as frequent as the pulse, the heart pulsating about 150
or 160 per minute, while the pulse beat only eighty.
Autopsy. — The right lung contains crude tubercles over a great
extent. Pleura sound. Left lung almost universally adherent to the
ribs by thick tuberculous false membranes covered with albuminous
flakes; less numerous but more advanced tubercles than in the right
lung: some beginning to suppurate.
Pericardium universally adherent to the heart by false membranes
from one to three lines thick, which contain numerous tubercles, in
all respects similar to those of the pleuritic false membrane. Heart
three or four times as large as natural — hypertrophy of both ventri-
cles, but particularly of the left, of which the walls are very thick
and the cavity considerable. In the substance of the walls of the
right ventricle is a tuberculous tumor of six or eight lines in thick-
ness, and two or three inches in length, formed by a yellowish re-
sistent tissue more homogeneous at the border than in the centre.
Besides this principal tumor there exist several smaller, but in the
right ventricle exclusively. Orifices and great vessels healthy. The
base of the heart and the origin of the great vessels is encircled with
a considerable mass of tuberculous glands, which completely enve-
lop the pulmonary artery and aorta for several inches from their
origin. The glands are formed of a yellow, firm, resistent, tuber-
culous substance: one alone is softened. By their agglomeration they
form an irregular mass of several inches in diameter.
CASES. 541
Peritoneum granular. Mesenteric glands, also liver, spleen, and in-
testines, healthy.
Remarks. — This case is remarkable for the prevalence of the tu-
bercular diathesis. I have little doubt that the two beats of the heart
for one of the pulse were nothing more than the impulse and back-
stroke, which, as in the case of May, become very sensible and have
a jogging character when there is universal adhesion of the pericar-
dium.
Immense aneurism of the aorta in the substance of the left lung producing
hozmoplysis. Amaurosis. — Lafin, cook, set. 58, athletic, has enjoyed
good health until lately, has been seized within six weeks with head-
ache and complete amaurosis of the right eye, and incomplete of the
left: pupils are contracted and immovable. Complains of pain equally
in the back and the shoulders, by which he is obliged to remain seated
in bed. Pulse natural; appetite natural; neither cough nor expecto-
ration. Six weeks later, he begins to cough and to expectorate con-
siderable quantities of blood: the cough returns in paroxysms, and
almost always brings a considerable quantity of scarlet and almost
pure blood. Respiration is feeble over the whole right side, particu-
larly high up. Heart presents signs of dilatation of the right side.
Pulse full, frequent and smart.
He was blooded and cupped several times: the blood being always
bulled. The haemoptysis continued and became black like prune-
juice, and was accompanied with extensive mucous rale over the
whole left side. Respiration hurried, incomplete. Died on the 17th
day of the haemoptysis.
Autopsy. — Extremely capacious chest, no emaciation, the left lung
is universally adherent to the costal pleura by a thick fibro-cellular
membrane infiltrated with serum. Its superior lobe contains an
aneurismal sac of the size of a cocoa-nut. The sac is formed by the
ascending aorta two inches above its escape from the pericardium:
its internal surface is smooth: the internal membrane of the artery may
be traced over a breadth of about two fingers: the rest of the sac is
formed by the middle coat, which presents linear furrows that do not
alter the polish of the surface. Outside of the sac are found fibri-
nous layers, less organized in proportion as they are more external:
the last, which are in contact with the lung, seem formed by coa-
gulated blood alone.
After having removed the aneurismal sac, the superior lobe of the
lung is found reduced to a mere membrane composed of condensed
pulmonary tissue: the air vesicles, the bronchial tubes and the blood
vessels open directly on the internal surface of the covering of the
aneurismal sac, and are thus in immediate contact with the tumor,
which, by its size, has caused absorption of a great part of this lobe.
Beyond the aneurism, the aorta is dilated as far as within three
fingers' breadth of the cceliac trunk: its internal surface is rugous over
the whole of this extent, and some cartilaginous points are observed
in the thoracic portion.
Heart tolerably voluminous; all its cavities dilated. No contrac-
tion of orifices.
12— k 37 hope
542 HOPE ON DISEASES OF THE HEART.
The inferior lobe of the left lung is infiltrated with pus, and pre-
sents several lumps of ramollissement: some softened tubercles in
that part of the superior lobe which is in contact with the tumor;
none elsewhere.
The right lung is gorged with serum, and presents several lumps
of gray ramollissement. The bronchi are red and tumified.
The second dorsal vertebra presents a commencement of caries,
the left part of its body being destroyed over an extent of three lines
at the point corresponding with the aneurismal sac.
Opacity of the arachnoid coat and of the pia mater: serum between
tnese two membranes.
Slight atrophy of the left optic nerve after the decussation.
Remarks. — Could so large an aneurismal tumor have been pro-
duced in the short space of ten weeks, especially considering that the
middle arterial coat extended throughout the whole tumor and the
internal over a considerable portion? If it existed previously, it is
remarkable that the patient should have enjoyed robust health, with-
out either cough or expectoration.
For ten more cases of aneurism of the aorta by the author, the
reader is referred to the London Medical Gazette, September 5th
and 12th, 1829.
The following case is a curiosity, as it presents a greater number
of different murmurs, (namely, six, including that rare one — the di-
rect mitral,) than I have heard in any other instance: yet it will be
seen that they were unravelled with the greatest clearness by a stu-
dent! This gentleman was Mr. James Freeman, a pupil of my class
on the practice of medicine, who brilliantly won my prize for auscul-
tation for the year. 1 give the case in his own words, the accuracy
of which 1 have verified by a personal examination of the patient.
Aneurism of the aorta: aortic regurgitation; mitral contraction and
regurgitation, with two murmurs. — "John Goff, aged fifty-five years,
in St. Bartholomew's Hospital, May 4, 1S39.
" History. — About nine months ago, had a violent blow on the
right side of the chest from the collar of a horse: did not feel much
illness at the time; but, about a fortnight afterwards, was attacked
with haemoptysis, and coughed up blood ' by the tea-cupful.'.
" Present symptoms. — 1. The face is very pallid. 2. He has had
no haemoptysis for the last seven weeks. 3. When admitted he was
compelled to lie on the right side, but he can now lie on the back,
or on cither side. 4. The anterior and superior part of the right
chest is dull on percussion. The dulness is complete between the
third and fifth ribs; it is less complete above the third rib, but it
evidently exists as high as the clavicle. 5. The respiratory murmur
is deficient over the part that is dull, the deficiency being slight be-
tween the third rib and the clavicle. 6. The respiration is slightly
puerile in other parts of the chest. 7. There is an obvious promi-
nence of the right side, at the part where the dulness is complete.
iS. There is a strong pulsation between the third and fourth ribs
about one inch and a half to the right of the sternum. 9. The pul-
cases. 543
sation is occasionally, bat not constantly, accompanied by a purring
tremor. 10. There is no preternatural pulsation above the clavicles.
11. There is no tremor above the clavicles. 12. The impulse of the
heart is natural.
" 13. Theirs* sound is accompanied,
" a. With a near, loud, and slightly rough murmur, loudest between
the second and third ribs, about an inch to the right of the sternum;
which is heard to a considerable distance, but with diminishing in-
tensity as we depart from that place.
" b. Over the apex, a murmur is heard with the first sound, loudest
in that situation, and rapidly diminishing as the stethoscope is ap-
plied above the apex.
"c. Over the humeral ends of the clavicles there is a near and sharp
murmur, probably generated in the subclavian artery.
" 14. The second sound is accompanied,
"a. With a soft and very prolonged murmur, heard loudest about
the lower edge of the third rib, at the right margin of the sternum.
It is heard with diminishing intensity below this, along the right
margin of the sternum. It is decidedly louder on the right than the
left side.
" b. The second sound is accompanied with a prolonged, soft, saw-
ing murmur, about the pitch of the whispered letters awe, over the
apex. It is heard in by far its greatest intensity over the apex, and
is greatly and palpably diminished (almost lost) on applying the in-
strument an inch or two above that place.
" 15. The sounds are slightly audible on the back. 16. The pulse
is eminently 'jerking,' and slow (60); it is accurately expressed as
c celer et infrequens.' 17. There is no venous murmur. IS. The
patient has never had rheumatism, and cannot give any account in-
dicative of his having had a diseased heart previously to the accident
with the horse.
"Diagnosis. — 1. Aneurism of the aorta. 2. Regurgitation through
the aortic valves, or from the aneurism into the right ventricle. 3.
Contraction of the mitral orifice, or some obstruction to the ingress
of blood through the orifice. 4. Regurgitation through the mitral
valve."
Remarks on Mr. Freeman's case. The signs up to 13, inclusive,
indicate an aneurism of the ascending aorta. The lowness of its si-
tuation denotes that it springs from near the origin of the vessel, —
whence, it probably implicates the aortic valves, as in fig. 13. The
murmurs over the numeral ends of the clavicles are subclavian; but,
over the sternal ends, they had an abrupt, hoarse intensity, which is
usually connected with disease of the interior of the aortic arch.
The murmur a, with the second sound, coinciding with the emi-
nently jerking pulse, indicates regurgitation through the aortic valves.
This murmur is heard more to the right than usual, in consequence
of the aorta being a little displaced in that direction by the aneuris-
mal tumor, which, when impacted between the sternum and spine,
generally slips to the right, where there is less pressure, Mr. Free-
544 HOPE ON DISEASES OF THE HEART.
man puts the alternative of the regurgitation being " from the aneu-
rism into the right ventricle." This is a fair and shrewd alternative,
and it is drawn from a supposed analogy with the case of Mitchell,
p. 437, and fig. 21. This view, however, is discountenanced by the
facts, '1. That, in the case of Goff, the murmur was that of an ordi-
nary semilunar regurgitation, whereas, in Mitchell, it was anoma-
lously loud, rough, and continuous; 2. That, in Goff, there was no
venous lividity from intermixture of arterial and venous blood; and
3. That there was no dropsical tendency, which symptoms were
highly marked in Mitchell (see Signs, p. 441).
The two murmurs at the apex denote the mitral contraction and
regurgitation; but the regularity of the pulse and the continuance
of its jerk, indicate that they are not very great. The prolonged
character of the direct mitral murmur — in short, its close analogy
to the murmur of semilunar regurgitation, is well worthy of remark.
I have not noticed this character in any other case. It remains tq
be ascertained by farther observations, whether it is constant.
DESCRIPTION OF THE PLATES.
FIG. 1 (the frontispiece) illustrates the description given at p. 30,
of the situation of the heart and great vessels with respect to the ex-
terior. The patient is supposed to be horizontal: when erect, the
heart is a little lower. The Fig. also illustrates the situation of the
jugular veins, vena innominata, and carotid arteries, described at p.
131, in reference to venous murmurs.
a. The internal jugular vein, running in front of the carotid artery,
along the anterior margin of the sterno-mastoid muscle, immediately
beneath the integuments and platysma myoides.
b. The external jugular vein.
c. Oblique section of the sterno-mastoid muscle, which crosses the
internal jugular vein at its lowest part.
d. The thyroid gland.
e. The trachaca.
/. The arteria innominata.
g. The left carotid.
h. The subclavian artery.
i. The clavicle, cut short.
k. The vena innominata.
/. The arch of the aorta,
m. The pulmonary artery,
n. The right auricle.
o. The right ventricle.
p. The appendix of the left auricle.
q. The left ventricle.
The sternum and ribs are represented in dotted outline. The ribs
are numbered 1, 2, &c.
FIG. 2. — This and the following figure are introduced for the pur-
pose of showing the exact situation and mode of action of the auri-
cular valves and their columnar carneae — a subject little understood,
and of which I have seen no good plates. I selected the most healthy
heart with which I could meet, (from an adult female of average size),
and made fac-simile drawings.
a. The aorta.
b. Pulmonary artery.
c. d, e. Three pulmonic valves, d being central and posterior.
/. A muscular prominence, from which proceeds a great number
of very fine tendinous chords to the anterior lamina of the tricuspid
valve,
37*
546 HOPE ON DISEASES OF THE HEART.
g. The anterior lamina of the valve, strengthened by a tendinous
chord radiating in a fan-like manner from the columna carnea, i.
h. The third principal division of the valve, partly anterior and
partly, posterior, springing from a columna carnea, behind the one i,
and sending a long tendinous chord upwards to the posterior lamina
of the valve.
i. A columna carnea, which, with a portion of the ventricular wall
I, has been separated from the cut edge m. The columna springs pos-
teriorly from the septum ventriculorum, and naturally draws nearly
in the direction g m.
k. Six fine tendinous chords springing from the posterior part of
the septum, and going to the posterior lamina of the valve.
/. Cut edge of the ventricle corresponding with the edge m.
Remarks. — The valve and its columnse carnese are situated entirely
at the posterior side of the ventricle, so that, when the blood has
entered, it is wholly in front of them. During the ventricular con-
traction, the blood presses the two laminae of the valve not only flat
against each other, but also against the posterior wall of the ventricle;
whence the valve is entirely withdrawn from the current of the blood,
and presents no obstacle to its egress through the pulmonary artery.
It is, in short, strictly an oblique valve, shut by its own contents,
like the valves of the ureters.
The objects of the columnar carnese are, 1. gently to draw down
the upper lamina of the valve after the diastole, preparatory to its
complete occlusion by the pressure of the blood in front during the
systole: 2. to hold the valve firm, and prevent its being forced back
into the auricle, during the systole. This is probably assisted by a
contractile shortening of the columnae carneae, which maintains the
valve in situ by countervailing the contraction of the apex towards
the base — a movement tending to give too much latitude to the valve.
As the columnae carneae spring from near the apex, it is obvious
why the sound of the valve is better transmitted to this part than to
the front of the base, opposite to the orifice, where the sound has to
be transmitted through the mass of blood in front of the valve. This
illustrates what is stated at p. 90 and 115 respecting the situations in
which to explore the sounds of the auricular valves.
Mr. King and others have imagined that the tricuspid valve natu-
rally admits of regurgitation, and, in so doing, exercises a safety-valve
function. It is credible that it may shut out any redundancy of blood,
but 1 do not believe that, when once closed, it admits of regurgitation :
1. because the structure of the valve is, in my opinion, distinctly op-
posed to such a doctrine; 2. because no murmur attends the first
sound — an argument which alone would be conclusive to an auscul-
tator.
FIG. 3 represents the interior of the left ventricle and the mitral
valve.
a. Aorca.
b. Interior of the pulmonary artery.
DESCRIPTION OF THE PLATES. 547
c. Portion of a pulmonic valve, cut from
d. The remaining portion.
e and/! The two other pulmonic valves. It is thus seen that the
pulmonic valves are seated about half an inch higher up than
g. The aortic valves.
h. Anterior lamina of the mitral valve, fully half an inch broad, and
situated almost immediately below the central and posterior aortic
valve g.
i. A columna carnea sending its chordae tendineae over a probe to
the anterior lamina of the valve, on which they radiate.
k. Another columna carnea sending its chordae in a similar man-
ner to the other corner of the anterior lamina. When the ventricle
is in its natural closed state, this columna falls into the shady de-
pression n between fcandz, and is almost in contact with the columna,?.
I. Posterior division of the columna ?, sending its chords to the
posterior lamina of the valve, which is only about a quarter of an
inch broad.
m. A second posterior columna sending its chords to the posterior
lamina. This columna is, in the present instance and in Fig. 20, a
part of the mass i; but, in other instances, as Figs. 5 and 7, it forms
the posterior division of the mass fc.
n. The depression into which the columna k falls.
o. Section of the ventricular walls, made close to the septum, and
passing through the apex.
Remarks. — It is seen that the valve and columnae are situated en-
tirely at the posterior part of the ventricle, and that the columnae
draw almost straight downwards towards the apex. The mode of
action of the valve, and the transmission of its sounds to the apex, are
exactly the same as in the case of the tricuspid valve (see Fig. 2,
Remarks).
Mr. Mayo appears to have been the first who pointed out the prin-
ciple upon which the auricular valves close their respective orifices
(see Med. Gaz. Aug. 10, 1833, p. 635).
FIG. 4. A. B. and C. It is suggested to the young student to carry
these three diagrams, with their descriptions, in his pocket, till he is
master of the subject. They illustrate the descriptions given in the
sections p. 95 and 114, where further details will be found. They
also apply to the summary of the physical signs of valvular disease at
p. 364, et seq.
Each of the four orifices of the heart may, by disease of its valves,
be the seat of two murmurs, — one, from the blood flowing in its na-
tural direction; the other, from its regurgitating or flowing retrograde
through the permanently open valve. The former murmurs may
be called direct; the latter, regurgitant.
They are represented by the two following diagrams, which apply
equally to both ventricles, though drawn in reference to the left only.
Diagram 4. A. The ventricle is supposed to be in the state of
systole.
548 HOPE ON DISEASES OF THE HEART.
a. Is a direct aortic or pulmonic murmur.
b. Is a regurgitant mitral or (in the case of the right ventricle) tri-
cuspid murmur.
Diagram 4. B. The ventricle is now supposed to be in the state
of diastole.
a. Is a regurgitant aortic or pulmonic murmur.
b. Is a direct mitral or tricuspid murmur, (which is extremely rare,
often absent though the valve be contracted, always feeble, and, in
the case of Goff, p. 542, it was prolonged like a semilunar regurgitant
murmur, but I am not yet sure that this character is constant).
Diagram 4. C. represents the situations where the murmurs of the
respective valves are most audible, and affords the principal data for
the differential diagnosis.
a. About two inches up the aorta.
b. About two inches up the pulmonary artery.
c. Over the two sets of semilunar valves, at the level of
d. d. The inferior margin of the third rib, when the patient is
horizontal. When he is erect, the valves are drawn a little lower
down.
e. The right auricular orifice (see Fig. 2).
f. The right columnge carnese and chordae tendineae.
g. The left auricular orifice (see Fig. 3).
h. The left columnae carneae and chordae tendinese.
Differential diagnosis of diseases of the semilunar valves. — A mur-
mur with the first sound at c, if distinct at a, is aortic: as a pulmo-
nic murmur is only feebly transmitted, and on a lower key, in that
direction.
A murmur with the first sound at c, if distinct at b, is pulmonic;
as an aortic murmur is only feebly transmitted, and on a lower key,
in that direction.
A prolonged murmur with the second sound, loudest at c, is from
semilunar regurgitation. It is aortic, if the murmur is loudest in
the direction a h, gradually diminishing on descending from c down
the ventricle. It is pulmonic, if loudest in the direction b f, gradu-
ally diminishing on descending from c down the ventricle.
A murmur with either sound, if distinct at a or 6, is semilunar;
as an auricular murmur is either inaudible or very feeble, and on a
low key, so far off.
Differential diagnosis of diseases of the auricular valves. — A mur-
mur with the first sound, loudest at h, (which is about where the
apex impinges, and a little to the sternal side of the nipple,) is from
mitral regurgitation: as a tricuspid regurgitant murmur is compara-
tively feeble in that situation.
A murmur with the first sound, loudest at f (which is about the
same level as h, but under the sternum,) is from tricuspid regurgita-
tion; as a mitral regurgitant murmur is comparatively feeble in that
situation.
A murmur with the second sound, loudest at A, is from contraction
of the mitral valve: one, loudest at f, is from contraction of the
tricuspid.
DESCRIPTION OF THE PLATES. 549
A murmur with either sound, loudest at h or f, is auricular; as a
semilunar murmur is very weak, on a low key, and sometimes wholly
inaudible, so far off.
FIG. 5. Thickening and contraction of the mitral valve, with
thickening and shortening of the chordae tendineae.
a. b. The anterior lamina, cut through its middle into the auricle,
and held open by two threads, to display the posterior lamina c. d.
which presents a thickened ridge. The two laminae are agglutinated
together at their extremities d and c; whence the total circumference
is diminished, being only 2g inches instead of 3% (see p. 290).
e e and //are the two double masses of columnee carneec, the an-
terior sending chords to the anterior lamina, and ihe posterior to the
posterior. The chords, especially the anterior, are seen to be con-
siderably thickened and shortened.
Remarks. — When the chordse tendineae are shortened, as in this
instance, they cause the superior lamina of the valve to be held
slightly open by the columnae carneae, when all the parts are put on the
stretch during the ventricular systole. The mechanism of this will
be very evident to one who has studied Figs. 2 and 3. Yet it is a
lesion almost constantly overlooked. The regurgitation is favoured
by prominences on the edges or expansions of the lamina?, (as the
ridge c d,) preventing their close apposition; for the blood then in-
sinuates itself between the laminae by a wedge-like process.
The patient, Charles Porter, aet. 13, was in St. George's, March
15, 183G. A murmur with the first sound was heard very distinctly
towards the apex (mitral regurgitation). Communicated by Dr.
Nairne.
FIG. 6, represents a great degree of fibrous thickening and con-
traction of the aortic valves, from endocarditis. A lump of this
fibrous tissue, as large as a pea, existed in the inside of the central
valve, and raised it externally at a. I did not see the patient during
life.
FIG. 7. This is introduced to exhibit a greater degree of thicken-
ing and shortening of the chordae tendineae and contraction of the
aperture of the valve, than Fig. 5.
a. a. The right columna carnea, consisting of the anterior and
posterior divisions, — each sending chords to the corresponding lami-
na of the valve.
6. A greatly thickened and shortened mass of agglutinated tendi-
nous chords, going to the anterior lamina, c. Posterior chords.
d. d. The left columna carnea, which has been cut from its origin
e,/, and drawn aside. It consists of the anterior and posterior divi-
sions,— each sending short and thick chords to the corresponding
lamina.
e. /. The point from which the columna d d has been cut.
g. Jl. Chords going from d d to the anterior and posterior laminae.
550 HOPE ON DISEASES OF THE HEART.
i. Boundary of the anterior lamina.
k. k. Aortic valves.
Remarks. — The valvular aperture was contracted by thickening,
and by the agglutination of the ends of the two laminae, so as barely
to admit the point of the first finger.
"A blowing first sound was heard over the region of the mitral
valve — most distinct towards the apex" (Dr. Nairne). The patient
was Peter Crump, in St. George's, March 22, 1836.
FIGS. 8 and 9. a. The arteria innominata, cut open.
b. Orifice of the subclavian.
c. A thickened and steatomatous flap of the internal membrane,
moveable up and down, so that, when up, it shuts back upon the
orifice of the subclavian b, and closes it like a valve — whence this
artery and its branches were pulseless.
The lesion originated in steatomatous disease, which had led to a
rupture and dissecting up of the internal membrane. The interior
of the whole ascending aorta and arch was exceedingly steatomatous,
and the vessel was dilated to about three times its natural size. At
one point it had formed a pouch, which bulged against, and finally
burst into the lungs, and was fatal by hemorrhage. The patient was
in St. George's, Sept. 19, 1837.
FIGS. 10 and 11. The angle (a Fig. 11) of one of the aortic
valves torn from its origin, and the flap hanging back, so as to admit
of regurgitation, which was attended with a loud musical murmur.
Fig. 10, a, represents a perforation in the same flap. The other
valves are thickened. See case of Milton, p. 526, and musical mur-
murs, p. 130.
FIG. 12. Contraction of the mitral valve, from hypertrophy of
the fibrous tissue and adhesion of the two laminae, with shortening
and thickening of the tendinous chords, whence regurgitation and
murmur.
a and b. The two divisions of the right columna carnea, the divi-
sion a being cut short and turned up.
c. The two divisions of the left columna, cut short and held out.
d. Left auricle.
FIG. 13. a, an aneurism of the aorta as large as a bantam's egg.
6, c. The edges of two valves, depressed by the aneurism, thick-
ened by fibro-cartilage, and everted, whence free regurgitation and a
murmur.
d. Third valve, much contracted.'
e. e. Steatomata. (See case of Williams, p. 523).
FIG. 14. Fibrous thickening of the aortic valves, especially the
valve c. It occasioned a direct, and a regurgitant murmur. In St.
George's, May, 1838.
DESCRIPTION OF THE PLATES. 551
FIG. 14. Ji. Extraordinary disease of the aortic valves. They
hung loosely back into the ventricle, not offering the slightest resist-
ance to the blood. The valves a and c were thrown together into
one large, irregular flap, b is a rugged lump of mixed bone and
steatoma, very crisp and rotten. Similar bone edges the dependent
flap e. The membranous expansions of the valves were greatly
thickened by fibrous tissue, /and g are the two coronary arteries.
Patches of yellow steatoma, h h, are seen at the origin of the aorta.
The mitral valve d is healthy.
James Windsor, eet. 33, out-patient at St. George's, June 20, 1838.
A double aortic murmur. Pulse 80, jerking. Diagnosis. Aortic
contraction and regurgitation. No mitral disease.
July 2. Pain in right side last week. Side dull over lower half;
no respiratory murmur, crepitant rale, or fremitus; aegophony: dry
cough. Diagnosis. Acute pleurisy with effusion, He did not re-
turn, but died.
The gentleman who made the examination informed me that 1 had
committed an error in diagnosis, the aortic valves being sound and
the mitral diseased. I ventured to express myself incapable of being
convinced, except by seeing the preparation. It was sent. He had
mistaken the aortic for the mitral valve. I have so frequently seen
similar mistakes, that I never hold myself responsible for any dia-
gnosis not given in writing, and of which I do not personally witness
the post-mortem results.
FIG. 15. a. The three aortic valves, stiffish with calcareous scales
of opaque yellowish-white colour. A ring of bone as thick as a quill
encircles the aortic orifice at b, but is concealed by the lining mem-
brane. A similar ring, c, equally thick, encircles the base of the mi-
tral valve. In parts, it is denuded and rough: elsewhere, the lining
membrane invests it like a blue film.
The patient was in St. George's, under Mr. Babington, and had
attained the age of 80 without complaining of symptoms of disease
of the heart. The aorta and coronary artery were also ossified.
This case is referred to at p. 261.
FIG. 16. a and b are rough calcareous concretions from the aortic
valves: c was a smoother one. They projected into the vessel, and
caused loud rasping murmur. The reasons are explained at p. 107.
The pulse was little affected in fulness, firmness, and regularity.
See p. 361.
FIG. 17. The aortic valves seen from the ventricular side. They
are agglutinated togelher, and form a fibro-cartiiaginous ring, a. See
case of Hedgley. The pulse was small, weak, and unequal, for the
reasons of which see p. 361.
FIG. 18. A dried preparation of ossified aortic valves, viewed from
the aortic side. The valves c, are curled and contracted, and project
552 HOPE ON DISEASES OF THE HEART.
in the closed position into the interior of the vessel, so as greatly to
contract the orifice, a are two flaps of the arterial walls peeled off
b, to sl^ow thafthe valve and its base are converted into one thick,
osseous mass. The surface of the concretions is everywhere granu-
lar and rough.
FIG. 19. Steatomatous and calcareous disease of the interior of
the aorta, a, the opening into the arteria innominata: b, into the
left carotid, thrown much to one side: c, into the left subclavian.
All are much contracted. This Fig. illustrates p. 394.
FIG. 20. An ossified aneurism as large as an egg, in the muscular
substance of the left ventricle, communicating with the aorta by an
aperture as large as a swan-quill, under the base of one of the sig-
moid valves. The aperture originated in steatomatous disease. A
stick a is passed through it from the aorta b, and emerges by a second
opening, d, e, into the cavity of the ventricle. The latter opening
is enlarged by a slit to the right, better to display the interior of the
aneurism, the walls of which are perfectly hard and rigid, except at
the slit, d, where they are fibro-cartilaginous. The bases of the
other sigmoid valves, c, c, are thickened and elevated by steatomata.
/ is the anterior, and g the posterior, lamina of the mitral valve; h
is the right columna carnea, which is triple; i is the left mass, which
is single; both are exceedingly hypertrophous. k is the wall of the
ventricle an inch and a quarter thick.
Remarks. — This case is referred to at p. 362. It is also an excel-
lent instance of hypertrophy. The patient was an old woman in
the St. Marylebone Infirmary, who laboured under aggravated symp-
toms of organic disease of the heart. I did not see her during life.
The physical signs were not noticed.
FIG. 21. Aneurism of the aorta bursting into the right ventricle.
a, the pulmonary artery; b, an interval between the two pulmonic
valves c and d, through which regurgitation could take place; e, two
apertures through which the aneurism discharged the aortic blood
into the right ventricle; /, cavity of the ventricle.
See the remarkable case of John Mitchell, p. 437; and the
signs, p. 441.
FIG. 22. Plan of the degree of excavation suitable for the ear-
piece of a stethoscope. It suits almost every ear. See p. 116, note.
This is beyond comparison the most important part of the instrument.
The nature of the wood is of trifling importance, though, theoret-
ically, cedar is the best.
i
Fw l
* Jl
11/?
/'"
/"
7
V
9
Fig. 2
i
/'■
■^f
Fw 1
PL,/, ?
w
ll
, -
- it
'
/'
wmq
DESCRIPTION OF THE PLATES. 553
Reference to Plates 1 and 2 of Dissecting Aneurism.
PL I. Fig. 1. a. Left ventricle of the heart, opened from the apex to
the base.
b. Cardiac extremity of the aorta laid open, showing
the semilunar and mitral valves, and the orifices of
the coronary arteries.
c. Pulmonary artery.
d. Left auricle.
e. External vessel laid open in its entire extent, bring-
ing into view the aorta/.
g. Valvular opening through the serous coat, and partly
through the middle coat of the aorta; the wire h is
passed through the valve, or fissure, showing the
communication between the aorta proper and the
aneurismal channel, or external vessel.
?, k, I. Arteries giving off from the arch of the aorta;
they open into the external vessel at m, n, o, and also
communicate with the aorta as indicated by the dot-
ted lines.
p. Intercostal arteries of the right side of the thorax,
communicating with the aorta.
q. Intercostals of the left side opening into the exter-
nal vessel e.
r. Foramina between the aorta and external vessel.
s, s, s. Tendinous bands passing from the internal coat
of the external vessel, connecting it with the aorta.
t. Termination of the external vessel near the bifurca-
tion of the iliac arteries.
u. Arteries of the abdomen communicating with the
aorta.
v. Internal iliacs laid open.
Fig. 2. f Aorta.
p. External vessel laid open and terminating at t.
u. Orifices of the arteries, of the abdomen opening into
the aorta.
w. Serous coat of the internal iliac.
x. Muscular coat of internal iliac.
y. Cellular coat of internal iliac.
PI. II. Fig. I. a. The Heart.
b, b. Pulmonary artery.
c. Horizontal section of the aorta, showing the valvu-
lar opening, (into which the wire d is introduced,)
13— a 38 hope
554 HOPE ON DISEASES OF THE HEART.
by which a communication is established between
the aorta/,/,/, and the external vessel e, c, c.
e', e', /'. Sections of the coats of the external vessel or
aneurism, and aorta: e', e', internal coat of the ex-
ternal vessel laid back; /' internal coat of the aorta,
in which is much ossific deposit.
g. The innominata; /i, Left carotid; z, Left subclavian.
The innominata and carotid near their orifices are
also apparently double. In the innominata the ap-
pearance of the concentric vessel extends half an
inch; in the left carotid, two inches, whilst in the
left subclavian there is only a valvular septum at its
mouth between the aorta/, and the external vessel e.
n. 11, n. Wires which pass into the external vessels e, e,
e; whilst those marked m, m, m, pass through the
orifices opening into the aorta/,//.
p. Intercostals of the right side.
q. Intercostals of the left side.
Fig. 2. Dissection of the coats composing the vessels e and /.
1, 1,1, 1, 1, 1,1. Internal coat of the external ves-
sel e, e.
2, 2, 2, 2. Middle coat of the same vessel consisting
of muscular fibres.
3, 3. Cellular coat surrounding the external vessel, and
common to both on the posterior semicircumference
of the aorta.
4, 4. Proper fibrous coat of the aorta /.
5, 5. Serous coat of the aorta.
Fig. 3. Horizontal section of the vessels.
e. External vessel or dissecting aneurism.
/. Aorta.
1. Internal membrane of external vessel.
2. Middle coat of the same, composed of muscular
fibres, uniting and blending with middle coat of
aorta (5) in its posterior semicircumference at 6, 6.
3. Cellular coat investing the outer circumference of e,
and the posterior portion of/
4. Middle coat or yellow fibrous tissue of aorta.
p. Intercostal artery of right side communicating with
aorta.
q. Intercostal of left side, originating from the exter-
nal vessel.
555
TABLE OF PULSES OF DISEASE OF THE HEART.
(See Remarks, pages 358 — 60.)
Simple Hypertrophy of Left V.— Strong and tensely prolonged;
because the ventricle contracts powerfully but slowly, (p. 265).
Hypertrophy with Dilatation. — Strong, tensely prolonged, and
large; because the ventricle contracts powerfully, slowly, and expels
an increased quantity of blood (p. 265).
JV*. B. — If the above pulses be moderately accelerated, they become
"Hard.39 They may be rendered temporarily or permanently small
and weak by any debilitating causes, impairing the contractile power
of the heart. Also, by extreme palpitation and dyspnoea causing en-
gorgement of the organ.
Hypertrophy with Contraction. — Tense but small; and if the
contraction be considerable, it becomes weak as well as small, from
the insufficient quantity of blood propelled into the arteries (p. 265).
Dilatation with Hypertrophy, i. e. the dilatation being pre-
dominant— Large and rather prolonged, but soft; from the large capa-
city, but weakness of the ventricle (p. 265).
JV*. B. — This pulse, if accelerated, becomes "Bounding.99
Dilatation with Attenuation. — Large and weak, becoming
small in the last stage, when the ventricle is too weak to expel its
contents (p. 300).
Softening. — Small, weak, and more or less irregular, unequal and
intermittent, sometimes extremely so, in the late stages; from the
debility of the ventricle (p. 328.)
Free regurgitation through the Aortic Valves. — Emi-
nently jerking; from the arteries being unfilled (p. 362).
Contraction of the Aortic Valves. — Strength little impaired,
unless the contraction be very considerable. The regularity is sel-
dom affected, except by extreme contraction (p. 361).
Great contraction of, or free regurgitation through,
the Mitral Valve. — Small, weak, irregular, intermittent and unequal^
because contraction occasions an insufficient and irregular supply of
blood to the ventricle; and because regurgitation weakens the pulse,
in consequence of the resistance of the mitral valve being removed,
and disturbs its regularity, in consequence of rendering the supply
of blood less uniform (p. 359).
A large Polypus formed before death, — Suddenly causes a
small, weak, irregular, and intermittent pulse; because the polypus
chokes up the ventricle (p. 487).
556 HOPE ON DISEASES OF THE HEART.
Endocarditis with Polypus. — Ditto, (p. 215).
Pericarditis with much serous effusion compressing the
Heart.— Ditto (p. 167).
Remarks. — I hope hereafter to show that these pulses imitate all
those produced by ordinary diseases, &c: — consequently, that, unless
the pulses of disease of the heart be abstracted, the pulse is but a
fallacious guide in other diseases, As this abstraction, in a complete
manner, has hitherto been impossible, in consequence of the imper-
fect state of our knowledge respecting the pulses of disease of the
heart, the present Table is an attempt to supply that deficiency.
557
APPENDIX,
The patients to whom the following autopsies refer, having died after their
cases had passed through the press, I insert the morbid appearances, not only
as accurately verifying the diagnosis, but as being highly interesting and in-
structive.
V. . . . , Esq., whose case is detailed at p. 527.
The Diagnosis was — " Mitral regurgitation: contraction of the aortic valves
and regurgitation: little or no hypertrophy or dilatation."
Autopsy,* — The walls of the left ventricle were only a little thicker than
natural — barely exceeding half an inch, and the cavity was moderately dilated,
being about the size of a goose's egg. The walls of the right ventricle were
of natural thickness, and the cavity was slightly dilated. The aortic valves
presented the greatest degree of ossification that I have ever witnessed, and I
am not aware that a greater has been described by authors. The valves in their
closed position, their bases, and the whole circumference of the aorta, were
converted, with an exception presently to be noticed, into one solid, immovable
mass of bone, retaining the form of the valves and surrounding zone of the
aorta, but two to three lines thick, and presenting a scabrous and uneven sur-
face. In the centre, where the three valves meet, was a roundish aperture, two
lines in diameter; and from this to the circumference of the aorta was a slit,
formed by the unadherent margins of two valves, which were still flexible over
an extent of about a line on each side of the slit, and in contact so as to prevent
regurgitation, except through the central aperture. The mitral valve admitted
the passage of three fingers, but its margins were thickened and nodulated.
Some of the chords were slightly thickened, and the columnce carnesc were re-
markably thin and pointed, as if stretched from being too short.
Remarks. — The diagnosis was accurately verified. The hypertrophy and
dilatation, as anticipated, were not considerable, and they might have super-
vened during the year which intervened between my examination and his death.
The contraction of the aortic valves produced the musical murmur with the first
sound over and beyond them, together with the common murmur, which was
on a lower key than a whispered r, because, as predicted, the circulation
through the aorta was weak — a necessary consequence of the extraordinary de-
gree of valvular contraction. The central valvular aperture was the cause of
the regurgitation, and, as predicted from the weakness of the murmur, it was
not considerable, in consequence of the smallness of the aperture.
The state of the mitral valve was calculated to admit of regurgitation, yet
not to a considerable amount.
This case is not only interesting in reference to the two musical murmurs,
but important as substantiating the doctrines of the pulse broached at p. 361,
with respect to the aortic valves. The pulse was "small, weak, irregular, and
unequal." I contend that this (when not dependent on softening) is, as the
general rule, the pulse of great contraction of the mitral valve, or free regurgi-
tation through it, and that it is foreign to contraction of the aortic valves, unless
extreme. Now, in this case, there was no mitral contraction, and certainly
* The heart was obligingly brought to me, May 24th, by Mr. Eisdell, and is depo-
sited in the Museum of St. Georges Hospital
38*
558 HOPE ON DISEASES OF THE HEART.
little regurgitation; but there was an almost unexampled degree of contraction
of the aortic valves: consequently, the state of the pulse was, it may be fairly
contended, a result of the latter.
John Gqff, whose case is described at p. 542, died May 27th, and was examined
on the 28th. Mr. Freeman had seen him a few days before death, and found
the symptoms the same.
The sternum required to be dissected from an adherent fibro-cartilaginous
tumour underneath. The third right rib, one and a-half inch from the sternum,
was slightly eroded over an extent of about half an inch. The sternum itself
was also eroded over an extent of one and a-half inch long and half inch broad,
below and opposite to the same rib, the insertion of which was implicated in
the erosion. A circular surface of the sternum and ribs of at least two inches
in diameter, including the erosions, formed the anterior boundary of an aneu-
rism al sac.
The right pulmonary pleura was firmly adherent to the costal by fibro-cartila-
ginous tissue, over the upper half of the lung. The cavity below contained
seventy ounces of blood (separated into crassamentum and serum). The upper
lobe of the right lung was less crepitant and more dense than natural, having
the feel of flabby flesh (the carnification of Laennec, from compression).
The cavity of the aneurismal sac equalled the size of an average orange.
An aperture, through which the handle of a scalpel easily passed, existed at
the inferior and posterior part of the sac, and through this the blood had es-
caped into the cavity of the chest. The sac communicated with the aorta by
an irregularly rounded opening about the size of an egg, half an inch above the
valves. The interior of the sac was invested by the lining membrane, affected
with steatomatous and osseous disease, over about one-half of the posterior and
inferior part: over the remainder it was deficient, and thin fibrinous layers sup-
plied its place.
The pericardium was universally adherent by old, but lax cellular tissue,
which easily admitted of separation by the finger.
The right ventricle and its valves were healthy.
The three aortic valves were each smaller than natural by fully one-third, so
as necessarily to leave an interval between them when in the closed position.
The smallness was referable to fibrous thickening, (hypertrophy,) and the mem-
branous parts of the valves were corrugated transversely on themselves, so as
to be defective in depth.
The aorta above the valves was slightly dilated, and exceedingly rough from
steatomatous depositions with a little bone. A similar state existed, but in a
less degree, and without dilatation, along the whole arch, and a little beyond.
The same also extended up and beyond the innominata, and in a less degree
up the left carotid and subclavian. The anterior lamina of the mitral valve was
fully a line thick, and irregularly nodulated round the edge, from fibrous hyper-
trophy. The posterior lamina was similarly atFected, but in a less degree.
The valve admitted of the passage of two fingers easily, though closely, but not
of three.
Left ventricle healthy: auricles healthy.
Present, and signed by,
HUGH P. FULLER, M.R.C.S.
STEPHEN YELDHAM, M.R.C.S.
THOMAS ABRAHAM, M.R.C.S.L.
THOMAS BLYTH, M.R.C.S.L.
JOHN H. HOUGHTON, M.R.C.S.
FREDERICK DANFORD, M.R.C.S.
JAS. FREEMAN.
G. H. YOUNG.
APPENDIX. 559
Remarks. — The diagnosis of Mr. Freeman, and the remarks upon it by the
writer, were verified in every particular. The condensation of the superior
lobe of the right lung was indicated by the defective resonance and respiratory
murmur. The aneurism, its origin immediately above the valves, and the
diseased interior, without dilatation, of the arch of the aorta, were all correctly
indicated. The regurgitation through the aortic valves existed, as anticipated
-in my remarks. The mitral disease also existed, and, as foretold, was " not
very great." The murmur with the second sound in this valve must, I presume,
have been occasioned by the contracted state of the valve, (which admitted
two fingers only instead of three,) assisted by the nodulated state of the mar-
gins, two or three of the nodules being two or three lines thick. Another cir-
cumstance, inadvertently omitted in the autopsy, may be noticed. The chorda?
tendineae, at their insertion into the laminae of the valve, were subdivided and
reticulated in an unusual degree. It may be asked whether the filtration of
blood through the reticulations contributed, with the contraction and nodulation
of the valve, to produce the murmur with the second sound. The circumstance
is apparently trifling; yet every thing should be noticed so long as the precise
causes of the murmur in question, and of its frequent absence in greater degrees
of disease, are doubtful and under investigation. The regurgitant mitral mur-
mur was abundantly accounted for.
The jerk of the pulse resulted from the aortic regurgitation, assisted by the
anaemia. The diagnosis did not include adhesion of the pericardium, and this
circumstance corroborated the opinion offered at p. 19S-9, that adhesion cannot
in every case be predicted with absolute certainty. The reason why the cha-
racteristic signs (p. 199) were absent in the present instance, was, that the ad-
hesions were so loose and tender as still to allow considerable latitude of
motion; that the heart was pushed back by the aneurism in front, whence any
increased or double-jogging impulse was rendered less perceptible: and lastly,
that there was no hypertrophy.
I cannot but call attention to the circumstance that this singularly complex
case was completely unravelled by a young student, who, three months pre-
viously, had no knowledge of valvular diagnosis.
560
INDEX OF CASES.
A. B., 329
Adipose degeneration, three cases of, 335
A Genevese, 540
referred to, 340
Allen, John, 539
A . . . n, Esq., 537
Anderson, Christian, 515
referred to, 50, 80, 96, 101, 103,
104, 288, 348, 359, 371
Aneurism of the abdominal aorta, case of,
434
Aneurism situated immediately behind
the heart, 423
A r, Dr., 538
Bowden, Grace, 533
1 referred to, 14! , 368
Brown, James, 539
, referred to, 98, 312, 347
Bryant, Robert, 494
Carrington, 536
C n, Esq., 476
Collard, Richard, 496
Collins, Mary, 458
. referred to, 97, 100, 243,
348, 442, 457
Copas, John, 499
, referred to, 98, 164, 347, 362
Cyanosis, two cases of, 458
Dennis, Elizaheth, 516
, referred to, 101, 359
Dolan, John, 512
, referred to, 349,350,359,363
Evans, James, 439
, referred to, 362, 367
Fenn, Ann, 520
, referred to, 350
Franklin, James, 149
Gillan, Patrick, 503
1 referred to, 288
Goff, John, 542; autopsy, 558
Green, John, 498
Harrison, William, 520
, referred to, 199
Hedgley, William, 509
H...y,Esq., 102,302
Hill (see the old editions)
James, Phoebe, 134
, referred to, 367, 490
Jones, Robert, 528
L_ P— Miss, 532
referred to, 101, 108, 141, 369,
427, 458
M Miss, 490
Macearl, Henry, 507
Malformation, two cases of, 458
May, Joseph, 521
, referred to, 160, 164, 199,
347, 383
Milton, Henry, 526
referred to, 98, 111,202
Mitchell, John, 437
, referred to, 98, 100, 108,
141, 320, 362, 367, 397, 441 , 454, 456
Murmurs, three cases of anomalous, 375
N , Esq., 103
N . . . e. Miss, 539
Palpitation, eight cases of, (see Contents,
Palpitation,) 473
Payne, Benjamin, 513
— , referred to, 199, 362
P< d, Esq., 335
Porter, Richard, 508
f referred to, 163, 347
P r, Mr. 337
Pyke, Sarah, 539
R., Lady, 534
, referred to, 100, 224, 343, 369,
395
R., Master, 459
, referred to, 442, 457
Rogers, Edmond, 534
referred to, 442
R. S., Esq., 50
, referred to, 99
Saunders, Mr. Wm. 330
Sharpe, George, 517
, referred to, 103. 348, 359
Sir , Bart., 330
S n, Esq., 336
Snowden, John, 501
, referred to, 163
Softening, cases of, 329
Storer, Richard, 510
Tindall, Joseph, 530
, referred to, 111
Utero-placental murmur, cases of, 148
V , Esq., 527
autopsy, 557
-i referred to, 108, 111, 142, l referred to, 111
175,370,438,442 I W_, Esq, 525
Keith, David, 497
Lafin, 541
, referred to, 410
Lambert, William, 504
, referred to, 289
— 1— n, Mrs. 518
referred to, 102, 103, 288, 346, 371 ,
379
, referred to, 99, 366
Wetherly, Sarah, 531
, referred to, 30, 101, 141,
348, 369, 427, 442, 458
Williams, Charles, 523
, referred to, 437
Wood, Thomas, 50
561
ALPHABETICAL INDEX.*
Abscess in the heart, 201
Acids,, use of, in valvular disease, 392
Aconite, use of, in rheumatism, 187
Active aneurism (see Hypertrophy.)
Adhesion in acute pericarditis, object of,
159
, process of, 100
in chronic pericarditis, 164
causes enlargement of the
heart; 197. 277
, danger of, 19G
may remain after symptoms
cease, 173, 188
, signs of, 178,
198
(See cases of May. Harrison and Williams.)
Age, a cause of ossification, 220, 258,
345
, effect of, in hypertrophy, 2" 5
, effect of, in aneurism, 317
Air, change of, in dilatation, 310
Albertini and Valsalva, their treatment
of hvpertrophy and aneurism, 279, 341,
443
Anaemia, cause of murmur in hypertro-
phy, 117
inorganic murmurs of
heart and arteries, 123
venous murmur, 140
purring tremor, 142
palpitation, 470
softening, 325
quick pulse after fe-
ver, 324
Anaemia, caused by treatment of aneu-
rism, 445
, caused by treatment of hypertro-
phy, 280
its influence or the pulse of hy- \
Anaemia, a fallacy in exploring dilatation
of the aorta, 4 20
, general symptoms of, 470
, treatment of, 284
Anaemic murmurs (see Inorganic Mur-
murs.}
in pregnancy. 1 >
(See Utero- Placental Murmur.)
pulsation of the abdominal aorta,
435
Anatomy of the heart, 29
Andral, M., on depositions in arteries,
227
, on hypertrophy, 249
, on ossification, 345
, on transformations of tis-
sues, 342
Aneurism, abdominal, case of, 434
fallacies of, 432
, signs of, 430, 434
Aneurism, thoracic, anatomy of, false,
398
, mixed, 399
, true, 396
, bursting into the
right ventricle, 437
-, bursting into the
pulmonary artery, 439
Aneurism, thoracic, classification of, 394
(See also Dilatation of the Aorta.)
, causes of, 399
causing continuous
murmur, 103
mor, 400
contents of the tu-
convalescence from,
447
diagnosis from val-
pertrophy, 205
vular disease, 419, 420
* Mr. James Freeman, to whom 1 am indebted for the following excellent Index,
says, rt 1 have adhered strictly to the alphabetical order in all the divisions and sub-
divisions. Everything in an index is second to convenience, and convenience of
reference is, in my opinion, only attainable by an unvaried alphabetical arrangement.
562
INDEX.
Aneurism, thoracic, fallacies of, 428
' , from hernia of the
internal membrane, 400
, how do they cause
erosion? 411
401
of, 408
burst, 410
422, 427
422, 428
413
418
heart, 423
400
420, 428
420
-, influence of sex in,
-, pathological effects
■, places where they
-, prognosis of, 447
-, pulsation of, 417,
, purring tremor of,
-, signs of, general,
-, signs of, physical,
-, situated behind the
-, size of the tumor,
-, sounds of, first, 419,
-, sounds of, second,
Aorta, thoracic, forms a fixed point for the
fibres of the heart, 85
, inflammation of (see Arte-
ritis.)
brane, 206
obliteration of, 443
-, redness of its internal mem-
. , roughness of, produces
murmur, 97, 366
, roughness of, produces tre-
mor, 141
-, transformations of the coats
of, 222
Apex, where it beats, 31
, in dilatation, 289
, in hypertrophy, 274
, how it strikes the inferior margin
of the fifth rib, and causes tinnitus, 73
(See cases of Jones, Carrington, A . . . n,
Esq., Dr A r.)
Apoplexy, from diseased cerebral arteries,
224, 259
dilatation, 301
hypertrophy, 256, 265
obstructed circulation, 260
ossification, 259
442
— , spontaneous cure of,
— , synopsis of signs of,
427
, treatment of, by Al-
bertini and Valsalva, 443
, treatment of, recom-
mended by the author, 445
perseverance in treat-
ment of, 447
Aneurism of the ventricles, anatomy of,
313
, causes of, 316
, influence of age in,
Arterial thrill (see Purring Tremor.)
Arterial varix, producing murmur and
thrill, 128
Arteritis, acute, anatomy of, 221
, signs of, 221
225
-, chronic, anatomy of, 222
, a cause of depositions,
229
signs
and treatment of,
317
316
320
-, influence of sex in,
-, pathology of, 326
-, signs of, general, 318
-, signs of, physical,
Artery, compression of, causes murmur,
105, 126
, depositions in the coats of, 222
, causes of, 225
, inflammation of (see Arteritis.)
-, redness of the internal membrane,
206
Aneurism of the auricles, 321
Angina pectoris (see Neuralgia.)
Antacids, use of, in valvular disease, 392
Antispasmodics, use of, in valvular dis-
ease, 391
Aorta, abdominal, anaemic pulsation of,
435
, treatment of, 448
, pulsation of, from
enteritis, 436
Aorta, thoracic, aneurism of (see Aneu-
rism,)
.' , course of, 31
■ ' , disease of the coats of, 222
, dilatation of (see Dilata-
tion,)
-, suppuration of, 224
-, ulceration of, 224
Ascites, case of, causing murmur, 375
Asperity of the aorta, 96, 366
of valves, 96
Ass, experiments on (see Experiments.)
Asthma, causes of, 375
, ultimate cause of, 376, 379
, from disease of the heart, 378
fit of, described, 381
, premonitory signs of, 382
, pulse in, 383
, subsidence of, 384
, modified by sleep, 380
, varieties of, 381
■, why worse at night, 383
Atrophy of the adipose tissue of the heart,
335
of the heart, 340
of the valves, 98, 102, 346
Attenuation, how it modifies the sounds,
313, (See Dilatation.)
INDEX.
563
Attrition sounds in pericarditis, 30G
, diagnosis of, from valvu-
lar murmurs, 174
Auricles, aneurism of, 321
— , dilatation of, 293, 294
, general signs of,
Bruit muscnlaire, diagnosis from jugular
murmur, 135
how far it causes the
303
— , physical signs of,
308
form a fulcrum beneath the ven-
tricles, 8G
, hypertrophy of, 243, 251
, general signs of,
209
, relative frequen-
cy of, 24G, 253
, never empty, 47
, repose of, its duration, 87
, sinuses of, always full, 85
, situation of, 31, 85
, systole of, described, 83
, attended with retrac-
tion, 40
pulse ? 83
first sound, 48, 75, 78, 135
Calcareous degeneration, 222, 223
225
substance, 338
, causing ulcer,
• of the muscular
•of the valves, 306
Cancer of the heart, 340
Carditis, combined with pericarditis, 108
, partial, 201
. general, 200
, does it cause an im-
, inconsiderable, 42, 40
, increased by palpita-
■, in small animals, 42
, objects of, 84
, precedes ventricular
systole, 37, 40, 42, 45
, produces no sound, 47,
tion, 42, 83
Back-stroke, (see Diastolic Impulse.)
Beat of the heart described. 83
Belladonna, applied to aneurism, 447
, for angina pectoris, 400
Bellows-murmur of Laennec, 100
, Laenncc's fallacies on,
30-1. (See Murmur.)
Bloodletting, a cause of polypi, 487
in aneurism, 443, 445
i dilatation. 311
hypertrophy, 279, 280
(See case of Macearl.)
pericarditis, 1!I0, 193, 190
rheumatism, 180
— valvular disease, 385, 380
Carotid aneurism, diagnosis of, from aor-
tic, 430
Cartilage, effect of aneurisms on, 412
Cases, 494
Cartilaginous deposition on valves, 244
in the muscular
substance, 339
in the pericar-
dium, 339
Chlorosis (see Anccmia,) 470
Chordae tendineae, shortening of, 101,340
Clavicles, dislocations of, by aneurisms,
413
Cliquetia (see Tinnitus.)
Colcbicum, use of, in rheumatism, 180
Colon, tumor in, a fallacy in aneurism, 433
Columnar carnea? in dilatation, 289
in hypertropby,242
Communication of the two sides of the
heart, 453
Complexion in dilatation, 301
in hypertrophy, 2G0
in soften in it, 325
Compression produced by aneurism, 409
Concretions in endocarditis, 213
causing murmur. 98, 487
— caused by digitalis, 440, 488
— , intestinal, a fallacy in aneu-
reaction from, 444
Bones, erosion of, by aneurism, 411, 413
Brain, congestion of, in dilatation, 301
, disease of arteries in, 224, 259
, effects of hypertrophy on, 250, 205
, effects of ossification on, 258
, inflammation of, in pericarditis, 104,
171
Bronchitis, diagnosis of, from pericardi-
tis, 172
, murmur in, 375
, purring tremor from, 415
, diagnosis of, 430
Bruit musculaire, probably only venous
murmur, 130
rism, 432 (See Polypus).
Configuration of an orifice modifies mur-
mur, 107
Continuous murmur, 108
(See I'cnous Murmur, Utcro-placcntal
Murmur, Pericarditis Murmur).
Contraction, hypertrophy with (see Hy-
pertrophy)
Convulsions of the heart, 4G1
Costal percussion, sound of (see Tinnitus)
Cougb in aneurism, 413
dilatation, 300
hypertroph}', 204
valvular disease, 358
Counter-irritation in endocarditis, 220
pericarditis, 193, 195
valvular disease, 390
Current of blood, its strength modifies
murmurs, 108, 112
Cyanosis (see Foramen Ovale), 456
from perforation, 201
Cysts in the heart, 340
564
INDEX.
Deformity of the chest or spine modifies
resonance on percussion, 35
Depositions in arteries, 223
. 1 , causes of, 225
, a cause of apo-
plexy, 258
. , from over-disten-
tion, 228, 259
Depth or hollowness of murmurs, 110
Destruction of parts by aneurism, 409
Diaphragm, tumor in, a fallacy in aneu-
rism, 432
Diaphoretics in valvular disease, 388
Diastole (see Ventricles)
Diastolic impulse in hypertrophy, 92, 270
Diet in aneurism, 447
dilatation, 310
endocarditis, 220
hypertrophy, 279, 281
pericarditis, acute, 192
, , chronic, 195
valvular disease, 385, 393
Digitalis, use of, causes polypi, 44G, 487
— - , in aneurism, 44G
. , in dilatation, 311
, endocarditis, 220
hypertrophy, 283, 285
, pericarditis, 193
in valvular disease, 392
Dilatation, anatomy of, 288
, auricular, signs of, 303, 308
, causes of, 251, 293, 310
, complicated with aneurism,
414
, complicated with valvular dis-
ease, 355, 358
, distinction of, from distention,
292
, extent of the sounds in, 305
, formation of, 293
, impulse in, 94, 303
, partial (see Jlncurism of Ven-
tricles)
, pathological effects of, 295
, prognosis of, 309
, progress and terminations of,
309
, pulse in, 300
, regurgitation and murmur
from, 101, 302
of the right ventricle, signs of,
302
— , signs of, general, 300
— , signs of, physical, 303
— , sounds in, 94, 304
— , treatment of, 310
- , varieties of, 288
Dilatation of the aorta, (see also Aneu-
rism,) 394
, anatomy of, 395
, formation of, 395
, pathological ef-
fects of, 408
from, 141, 422
purring tremor
Dilatation of the aorta, seat of, 395
, sounds in, 96, 421
, signs of, 426
treatment of, 448
Dilatation of the pulmonary artery, 395
, signs of, 427
Displacements of the heart, 490
Distention of arteries, a cause of deposi-
tions, 227
, the heart, 293
, distinguished from
dilatation, 292
, differs from fulness,
45,85
Diuretics, use of, in dilatation, 311
hypertrophy, 283
pericarditis, 194
valvular disease, 387
Dogs, experiments on, illustrative of inor-
ganic murmurs, 122
Dropsy in aneurism of the heart, 319
in dilatation, 296, 301
treatment of, 312
in hypertrophy, 254, 255, 266
, treatment of, 283
in pericarditis, 195
in valvular disease, treatment of,
387, 389
Dulness on percussion, natural extent of,
34
, causes counteract-
ing, 35
cic, 417
minal, 431,433
urn, 35, 492
173
172
• in aneurism, thora-
in aneurism, abdo-
in dilatation, 34, 307
in endocarditis, 216
in hydropericardi-
in hypertrophy, 274
in pericarditis, 170,
in peripneumony,
in pleurisy, 172
Dura mater, ossification of, 225
Dyspepsia producing palpitation, 468
cases of, 475, 480
Dyspnoea in aneurism of the aorta, 413,
416
in anuerism of the heart, 485
in dilatation, 300
in endocarditis, 214, 216
in hypertrophy, 254, 264
in pericarditis, 166, 167
in valvular disease, 358
Effusion in pericarditis, 162
■ — , absorption of, 188
, signs of, general, 1 67
, signs of, physical,
173
Elasticity of the heart, what, 29
of arteries, loss of, 222
Emetics, use of, in valvular disease, 389
INDEX.
565
Emphysema of the lungs modifies dul-
ness, 35, 274, 307
(See case of Keith.).
Endocarditis, anatomy of, 160, 204, 20G
, causes of, 218
, causing transformations, 339
, causing vegetations, 350
, coagulation of blood from,
212 (See case of Fenn.)
, complicated with pericardi-
tis, 162, 179,213
, dulness in, 216
• , duration of, 218
, impulse in, 216
, gangrene from, 212
, lymph effused in, 210
, pain in, 363
, prognosis of, 220
, progress of, 218
, pulse in, 214, 215
, redness of, 206, 210
, signs of, general, 21 1
, signs of, physical, 180, 216
, sounds in, 217
, summary of signs of, 213
, terminations of, 219
, treatment of, 220
, ulceration from, 212
Enteric inflammation, a cause of ventral
pulsation, 436
Excito-motory system, is it the agent of
the heart's movements ? 92
, the seat of asthma,
376
Expectorants in valvular disease, 390
Experiments on the rabbit and frog, 36
on the ass, first series, 39
, second series, 41
, repeated Aug. 10, 1831,44
, performed Nov. 3, 1834, 52
, performed Feb. 1835,53
, oricnnal-
Fever, symptomatic, of endocarditis, 214
, of pericarditis, 165
Fibrous deposit in arteries, 223
, in the heart, 338
Filing murmur of Laennec, what, 107
Foetal heart, beat of, characters of, 144
Foetal heart, beat of, exploration of, 143
, fallacies of, 144
, imitated by jerking
tape, 49
— , speed of, 144
— , time of the occur-
rence of, 144
-, value of, 146
ity of, 52
performed Aug. 7, 1835, 56
on doffs, illustrative of inor-
ganic murmurs, 122
Expiration, effect of, on the impulse and
sounds, 33
, on jugular tumes-
cence, 268
— , on the venous mur-
mur, 1 33
Extension, (see Muscular Extension)
External applications to aneurisms, 447
Eye, state of, in hypertrophy, 261
Faeces, indurated, a fallacy in aneurism,
432
False aneurism of the aorta, 394, 398
Fat, excess of, in the heart, 333, 338
, cases of, 335, 336,
337
Fever, pulse in, 204, 324
, redness of the endocardium in, 208
, rheumatic, (see Rheumatism)
13— b
, where most audible,
145
Foramen ovale, patescence of, 452
, cases of, 458, 459
, general signs of,
455
, physical signs of,
457
Friction, the cause of murmurs and tre-
mor, 105, 120
Fulness of the heart, differs from disten-
tion, 45, 84
Gangrene of the arteries, 222
of the heart, 203
from endocarditis, 212
of the legs from ossification, 224
Gases, use of, in valvular disease, 390
Glands, pulsating, a fallacy in aneurism,
429
Greasy degeneration of the heart, 334
Haemoptysis in hypertrophy, 261, 265
Heart, acts when removed from the body,
85
, adipose degeneration of, 333
, anatomy of, 29, 232
, aneurism of, 312
, asthma from disease of, 378
, atrophy of, 340
, diastole of, (see Ventricles)
, dilatation of, 288
, dimensions of, 232
, displacements of, 490
, distention of, 292
, first principle of the motion of, 91
, foetal, 143
, form of the cavities of, 292
, gangrene of, 203
, greasy degenerations of, 334
, hypertrophy of, 230
, induration of, 332
, inflammatory affections of, 156
, lining membrane of, 341
, malformations of, 449
, motions of, described, 83
, causes, mechanism, and
objects of, 84
, nervous affections of, 461
> organic diseases of, 230
, ossification of, 338
39 hope
566
INDEX.
Heart, pathological phenomena of the ac-
tion of, 92
, perforation of, 201
, repose of, (see ventricles)
, rupture of, 202, 291
, situation of, 30
, when enlarged, 32
, how altered by position, 33
, softening of, 321
, sounds of, (see Sounds)
, systole of, (see Ventricles)
- , weight of, 232
Hepatic artery, aneurism of, 433
Hernia of the internal membrane of arte-
ries, 400
Hum, venous (see Venous Murmur) 136
Hydremia (see Anaemia) 140
Hydropericardium, dulness in, 35, 492
, a fallacy in aneurism,
429
, signs of, 491
; , treatment of, 492
Hypertrophy, anatomy of, 240
, of the auricles, 243
, of the ventricles,
242
414
ease, 261
dium, 197
•, bloodletting in, 280
■, causes of, 244, 247
-, classification of, 231
-, complications of, 276, 358,
counteracted by valvular dis-
-, diet in, 281
-, dulness in, 275
-, formation of, 244
from adhesion of the pericar-
history of, 230
impulse in, 92, 269
-, with dilatation, 94
inflammatory, 248
-, order in which the clavicles
are affected by, 250
, pathological effects of, 253
, with contraction,
256, 263
, on the brain, 256
, on the lungs, 261
, prognosis of, 278, 284
, progress of, 275
, pulse in, 265
, relative frequency of forms
and seats of, 253
, signs of, general, 263, 275
, of the auricles,
269
triples, 267
of the right ven-
— , physical, 269
sounds in, 92, 273
, causes of their modifica-
tions, 93
-, terminations of, 275
-, treatment of, 278
Hypertrophy, treatment, success of, 285
, valves in, 244
, with contraction, does it ex-
ist? 287
Ice, application of, to aneurisms, 447
Iliac arteries, ossification of, 224
Impulse, caused by the ventricular sys-
tole, 43
, circumstances which diminish
the, 94
, coincides with the systole, 42
, in carditis, 200
, in dilatation, 93, 303
, in endocarditis, 214, 215
, in hydropericardium, 492
, in hypertrophy, 92, 269
, causes which diminish
the, 273
■ , with dilatation, 94,270
, in induration, 332
, in pericarditis, 174
, in softening, 327
, j°gging> 199, 424
, mechanism of, 85
, modified by posture, 33
Induration, anatomy of, 332
, impulse of, 332
, in hypertrophy, 240
, proof of inflammation, 200
, treatment of, 332
of valves, aortic, 347
, mitral, 344
, pulmonary, 348
, tricuspid, 348
Inequality of the pulse, what, 360
Inflammation, cause of ventricular aneu-
rism, 316
, depositions in arte-
ries, 225
1 hypertrophy, 248
, polypi, 485
j , softening, 321
, valvular disease, 356
, vegetations, 58, 350
, does it contribute to the
effects of aneurisms ? 412
Inorganic murmurs, 11.8
accompany arterial di-
astole, 120
accompany ventricular
systole, 120
, case of, by M. Bouil-
laud, 125
, caused by motion of
the blood, 120
, diagnosis from valvu-
lar murmur, 372-
, illustrated by experi-
ments on dogs, 122
Inorganic murmurs in pregnancy, 146,
148
, Laennec's views of,
118
, physical causes of, 124
INDEX.
567
Inorganic murmurs produced by anaemia,
127, 471
arterial varix, 123
compression, 125,
374
loss of blood, 127
nervous excitement,
128
Inspiration, effect of, on the impulse and
first sound, 33
on jugular tumes-
cence, 269
on the venous mur-
mur, 133
Intermission of the pulse, what, 3G0
Iron, use of, in anaemia, -172
, in dilatation, 311
, in softening, 323
Irregularity of the pulse, what, 360
Issues, use of, in valvular disease, 390, 124
Jogging impulse, from adhesion of the
pericardium, 199
— , from aneurism, 424
, from displacement, 424
Jugular vein, pulsating turgescence of, -
Measurements of the orifices, 290
Melanosis of the heart, 340
Membrane, lining, of the heart, 342
Mercury, use of, in endocarditis. 220
, in pericarditis, 192,195
, in rheumatism, 186
Mesentery, tumor of, a fallacy in aneu-
rism, 432
Metallic cliquetis of Laennec, cause of,
73
(See cases of Jones, Carrington, A. . . .n,
Esq., Dr. Ji....r.)
Migration of rheumatism, 185
Mixed aneurism of the aorta, 394, 399
Mucous membranes, injection of, 301
Murmur, anomalous cases of, 375
, continuous, 108, 175
from aneurism, abdominal, 431
, thoracic, 420
— attrition, 174
, diagnosis from valvular,
182
267
— compression, 54, 55, 80, 126
• — concretions in the heart, 98, 487
— endocarditis, 180
hypertrophy with dilatation, 94,
— , simple turgescence of, 303
— , varix of, a fallacy iu aneu-
117
Key, or pitch of valvular murmur, aortic,
109, 110
, mitral, 110
, pulmonic, 109
, tricuspid, 1 10
venous murmur, 130
Lead, acetate of, in aneurism, 446
Leeches in aneurism, 447
in pericarditis, 190, 193, 194, 196
Liver, congestion of, in dilatation, &c.
301
, enlargement of, a fallacy in aneu-
rism, 432
Lungs, murmur in aorta from disease of,
374
, situation of, over the heart, 31
, sounds heard through the, 55, 56,
71,306
, disease of, causing asthma, 376
, engorgement of, in hypertrophy,
255
, engorgement of, in dilatation, 300
, in valvular disease,
358
Lymph effused in endocarditis, 210
, organization
98
— ovarian tumor, 126
— pericarditis, 175
•- »- polypi, 98, 4-7
— roughness of the aorta, 97
regurgitations, 55, 57, 58, 80, 96,
inorganic, (see Inorgunic Murmurs,)
118
, musical, (see Musical Murmur,) 86
, utero-placental, (see Ulero'placental
Murmur,) 146
, venous, (see Venous Murmur,) 129
, valvular, (see Valvular Murmur,)
95
Muscular extension, described, 73
sound of, differs from bruit
musculaire, 74
, how far it contributes to
the first sound, 73
Musical murmur, 110
generally from regurgita-
tion, 112
, what indicated by, 112
, in the veins, 136
of, 213
in pericarditis, 153, 183
, signs of, 174
Magnet, use of, in neuralgia, 466
Malaria, a cause of neuralgia, 465
Malformations of the heart, (see Foramen
ovale,) 449
(See cases of Milton, V , Esq., James,
Tindall, Jones.)
Narcotics, use of, in neuralgia, 465
, in valvular disease, 475
Nervous murmur, (see Inorganic Mur-
mur,) 123
palpitation (see Palpitation)
pulsation of the abdominal aorta,
435
Neuralgia of the heart, or angina pectoris,
causes of, 463
, diagnosis of, 465
, nerve affected by, 464
, prognosis of, 465
568
INDEX.
Neuralgia, symptoms of, 461
, treatment of, 465
(Esophagus, compression of, by aneurism,
416
Omentum, tumor of, a fallacy in aneu-
rism, 432
Ophthalmic artery, how affected by hyper-
trophy, 261
Opium, use of, in neuralgia, 465
— , in rheumatism, 186
valvular disease, 475
Orifices, measurements of, 290
Ossification an attendant on age, 258, 345
, arterial, 223
, causes of, 225
, effects of, on the brain, 258
, is it natural to old age ? 345
, of the dura mater, 225
. of the substance of the heart,
338
-, of the ophthalmic artery, 261
-, of the pulmonary artery, 534
-, of the pleura, 225
., of the valves, aortic, 347
mitral, 344
pulmonary, 348
tricuspid, 348
, generally on the left side, 342
, why, 344
, causes of, 348
Ovarian tumor, causing aortic murmur,
126
, murmur mistaken
for uterine, 152
Pain in aneurism of the aorta, 416
of the heart, 318
dilatation, 302, 464
excess of fat, 333
endocarditis, 214
hypertrophy, 267, 464
, how relieved, 281
pericarditis, 165,170
valvular disease, 363
(See Neuralgia.)
Palpitation, auricular systole increased
by, 83
, causes of, 467
, definition and description of,
467
by, 88
— , impulse diminished by, 467
, in aneurism of the heart, 319
— dilatation, 300
— endocarditis, 214, 215
— hypertrophy, 263
— pericarditis, 166
interval of repose diminished
nervous, 468
, anaemic, 470
, cases of, 473, 480
, dyspeptic, 468
, from stimulant diet, 472
, plethoric, 473
Palpitation, pain occasioned by, 363
produces dilatation, 293
, sounds diminished by, 468
Pancreas, enlarged, a fallacy in aneurism,
432
Paralysis of the heart, 215, 461
Percussion of the heart, mode of, 33, 34
, theory of, 33
(See dulness on percussion.)
Perforation of the heart, 201
Pericarditis, adhesion from, object of, 159
process of, 160
^melioration, signs of, 172
, anatomy of, 156
, causes of, 184
, convalescence in, 193
, diagnosis of, 172
, effusion of, 162
— , endocarditis coexistent with,
164, 180
, impulse of, 174
, lymph effused in, 158
muscular substance affected in,
164
— , partial, 161
— , percussion in, 173
— , prognosis of, 188
— , progress of, 187
— , recurrence of, 193
— , redness of, 156
— , rheumatic, 184
— , signs of, 164
, general, 165
, diversities of, 166
, physical, 173
sounds ofj 174
, from attrition, 175
, from endocarditis, 180
, diagnosis of the two
classes, 182
, terminations of, 188
, transformations of false mem-
brane, 162
, treatment of, 190
, white spots from, 161
Pericarditis, chronic, anatomy of, 163
, signs of, general, 182
, chronic, signs of, physical,
183
treatment of, 195
Pericardium, adhesion of, (see Adhesion)
, bursting of aneurisms into,
410
, inflammation of, (see Peri-
carditis)
224
-, situation of, 32
, when full of fluid, 33
-, transformations of, 339
-, tumor in, causing murmur,
-, white spots on, 161
Peri pneumony, diagnosis of, from pericar-
ditis, 172
Peritonitis, aortic pulsations in, 436
Phlebitis, 221
INDEX.
569
Plates, description of, 545
Plessimeter, 33
Pleura, ossification of, 225
Pleurisy, complicating pericarditis, 1G8
, diagnosis of, from pericarditis, 172
Pneumopericardium, 493
Poisons, paralysis of the heart by, 215,
461
Polypus, anatomy of, 483
, unorganized, 483
, slightly organized,
483
-, more completely or-
ganized, 485
, causes of, 485
, inflammation, 485
, retarded circulation,
485
, formation of, 485
, nature of, 482
, signs of, general, 487
, physical, 487
, solubility of, 490
, treatment of, 488
Posture, effect of, on anaemic murmur,
432
aneurismal mur-
mur, 431
the first sound, 33
— impulse, 33
■second sound, 30
-, in acute pericarditis, 100
chronic pericarditis, 183
asthmatic fit, 382
Pregnancy, auscultation of, 143
(See Fecial, Heart, Uteroplacental Mur-\
mur.)
Prominence of the precordial region, 241,
275
Pulmonary apoplexy from dilatation, 300
hypertrophy, 202
, from mitral contrac-
tion, 251
softening, 332
Pulmonary artery, compression of by tu-
mor, 224
, course of, 30
, dilatation of, 395, 39G
, signs of, 427
, forms a fixed point for
the fibres of the heart, 85
-, inflammation of, (see
Pulse, in ansemia, 128
aneurism of the aorta, 414
dilatation, 300
endocarditis, 214, 215
fever, 204, 324
hypertrophy, 2G5
pericarditis, 16G, 170, 174
softening, 326
valvular disease, 358
, aortic contraction, 361
, aortic regurgitation, 362, 366
, mitral, 359
of the right side, 362
, jerking, 174, 128, 362, 366
, rapidity of, in rabbits, 88
should be felt when exploring
valvular murmurs, 116
Pulses, table of, in diseases of the heart,
555
Puncturing for dropsy, 389
Purgatives, use of, in aneurism, 445
hypertrophy, 282
pericarditis, 191
rheumatism, 186
valvular disease,
387
, influence of, on the dulness of
abdominal aneurism, 445
Purring Tremor accompanies arterial di-
astole, 120
ventricular
systole, 120
Arteritis.)
-, ossification of, 100,224
, sound high up the, 90
Pulsating glands, a fallacy in aneurism,
429
Pulsation, abdominal, from inflammation,
436
-, anoemic or nervous abdominal,
435
aneurismal, abdominal. 430
thoracic, 416, 427
427
in dilatation of aorta, 451
in dilatation of pulmonary artery,
, causes of, 120,123,141,142
— , experiments on dogs, 122
— in aneurism, 415, 422, 428
— ansemia, 122, 127
arterial varix, 128
— aortic dilatation, 425
— compression, 125
— endocarditis, 214
— pericarditis, 174, 182
— pulmonary dilatation, 427
— valvular disease, aortic, 367
, mitral, 58, 142, 369
, pulmonary, 369
, tricuspid, 141
-, Laennec's views on, 119
-, synopsis of phenomena of, 141
-, venous, 539
(See cases of Pyltc, Miss N . . .e.)
Pus effused in arteritis, 223
pericarditis, 163
Putrefaction resembling gangrene, 203
Quiescence, necessity of, in aneurism, 447
Rasping murmur of Laennec, what, 107
Redness, in endocarditis, 204
inflammatory, 210
, non-inflammatory,
206
pericarditis, 156
, its value as a sign of inflamma-
tion, 209
Regurgitation, murmur from, 55, 57, 58.
80, 96
570
INDEX.
Regurgitation, cause of, may be slight, 119
~ indicates organic disease,
, from shortening of the
chordae tendine®, 101, 340
, from enlarged orifice, 99,
102,
119,302
, rules for exploring, 115
, aortic, 98, 36b"
, character of its mur-
mur, 99
of, 100
174, 180
frequent occurrence
from aneurism, 98
from pericarditis,
, key of its murmur, 110
, murmur of, where best
heard, 99, 1 14
, prolongation of its mur-
mur, 99
, pulse of, 362, 366, 437
, mitral, 101
, key of, 1 10
, pulse of, 359
, recovery from, 302
, where best heard, 115
, pulmonary, 100
, key of, 110
, pulse of, 362
- , where best heard, 114
, tricuspid, 104
, key of, 110
, pulse of, 362
, where best heard, 115
Repose, interval of, 84
, duration of, 44, 87
, imperceptible during rapid action
Scale, Laennec's, of the extent of the
sounds, 305
Serous infiltration in dilatation, 267
, hypertrophy, 301
Setons, use of, in valvular disease, 390
Shock felt with the diastole, 57, 93, 270
systole, 54, 57, 74
Softening, anatomy of, 321, 325
, cases of, 329
, causes of, 321, 325
, diagnosis of, 327
, nature of, 321
: — , proof of inflammation, 200
, prognosis of, 328
, pulse of, 327
, red, 323
, signs of, general, 326
, supposed to be gangrene, 203
, treatment of, 32D
, varieties of. 322
, white, 324
, yellow, 325
, incompatible with distention, 87
, object of, 87
, admitted in Majendie's Theory, 87
Respiration, modifies impulse, 33
, jugular turgescence,
269
sounds, 33
venous murmur, 133
Sound, First, audible through lung, 55, 56,
, auricular valves contribute
to, 54, 58, 76
, bruit musculaire contributes
to, 75, 77, 89
, causes of, 43, 48, 73, 79, 89
, coincides with systole, 40, 41,
44
, double, 73, 537
, muscular extension contri-
butes to, 73, 89
, not occasioned by impulse, 71
, supposed to be imitated by
contraction of the abdominal muscles,
78
, where loudest, 49, 53, 57, 90
, second, cause of, 43, 49, 54, 55, 58,
79, 89, 439
, coincides with diastole, 42,
45,47
-, imitated by jerking tape, 49
here loudest, 30, 55, 90, 274
, suspension of, its effects, 46, 47,
95,216,378
Resonance on percussion, theory of, 34
Rheumatism, cause of endocarditis, 219
, cause of pericarditis, 171,185
, preceding arteritis, 222
, treatment of, 186
Rhythm of the heart, 43, 84
degrees of derangement of, 360
Ribs, erosion of, by aneurism, 413
, relation of, to heart and vessels, 30
Roughness of murmurs, on what depend-
ing, 107
, presumptions afforded by, 108,112
Rowing, excessive, a cause of hypertro-
phy,24?
Rupture of the heart, 202, 314
— — ^„_„: valves and aorta, 202
Sawing murmur of Laennec, whit, }06
Sounds, described, 35
-} diminished by compression, 425
, do they differ on the two sides?
76, 305
, duration of, 44
, extent of, 304
, heard at a distance from the pa-
tient, 339
, heard through fluid, 71
, heard through condensed lung,
306
in aneurism, 419
dilatation, 77, 89, 94, 304
endocarditis, 180, 216
excess of fat, 333
hydropericardium, 492
— -— - hypertrophy, 92, 273
—Z — =■— hypertrophy with dilatation,
~ 94,274
i— — — : pericarditis, 174
INDEX.
571
Sounds in polypus, 487
softening, 327
valvular disease, 95, 364
Spasm of the heart, 461
Spots, opake, white, on the heart, 161
Stags, arterial ossification in, 220
Staybones, pernicious effect of, 248
Steatomatous disease of arteries, 222, 223
Sternum, relation of objects behind the, 30
Stethoscope, 116
Stomach, schirrus of, fallacy in aneurism,
432
Subclavian aneurism, diagnosis from
aortic, 430
Syncope, 480
, treatment of, 481
Systole, (see Ventricles)
Utero-placental murmur, situation of, 147
, time of occur-
rence of, 146
Valves, anatomy of, in health, 341
, auricular, retropulsion of, contri-
butes to the impulse, 86
, situation of, auricular, 31
, semilunar, 30
, what included under the term,
76
Valvular disease, 341
, aggravated by hypertro-
phy and dilatation, 354
, anatomy of, 341
, aortic, 347
, mitral, 344
, on the right side,
Tape worms, mass of, fallacy in aneurism,
432
Tartar emetic, use of, in pericarditis, 192
Theories, erroneous or defective, on the
sounds of the heart, 80
Thrill (see Purring Tremor)
Throbbing (see Pulsation)
Tinnitus, metallic, of Laennec, its cause,
73
(See case of Jones, Carrington, A..n,
Esq., Dr. A.... r)
Tonics, use of, in dilatation, 311
valvular disease, 393
Trachsea, compression of, by aneurism, 416
Transformations of tissues, 228, 338, 342
, M. Andral on, 227
True aneurism of heart, 394, 396
(See Aneurism of the Ventricles)
Tubercles, case of, causing aortic mur
mur, 374
, referred to, 126
in the heart, 340
348
ma.)
, asthma from (see Asth-
, causes of, 348
, fallacies of, 374
, influence of age on, 345
, pain of, 363
, pathological effects of,
354
361
— , prognosis of, 364, 385
— , progress of, 363
— , pulse of, 358
, aortic contraction,
case of, 541
Ulcers in the heart, 201
, signs of, 201
in arteritis, 224
endocarditis, 212
Utero-placental murmur, 146
> , after foetal ex
pulsion, 154
148
362
aortic regurgitation,
146
149, 155
uterine arteries? 154
pregnancy, 153, 155
elusions on, 155
specting, 148
mors, 152
-, arterial whiff,
-, cases of, 143
-, characters of,
-, continuous, 148,
", is it sealed in
-, independent of
-, practical con-
-, propositions re-
-, simulated by tu-
, mitral, 359
, of the right side, 362
, seat of, 343
, signs of, general, 357
, physical, 364
, aortic contraction,
365
, aortic regurgitation,
366
, mitral, 369
(See case of Goff)
, pulmonary, 368
(See case of Bowden, Rogers)
, tricuspid, 372
(See Valvular Murmurs)
, signs of arterial and
auricular combined, 372
, terminations of, 364
, treatment of, 384
, antispasmodics, 391
, bloodletting, 386
, counter-irritation,
390
, diaphoretics, 388
, diet, 393
, diuretics, 387
, emetics, 389
, expectorants, 390
, gases, 390
■ , puncturing, 389
, purgatives, 387
Valvular disease, treatment of stomachics,
392
572
INDEX.
Valvular disease, treatment of tonics, 393
, why generally on the
left side, 343
Valvular murmurs, 95
, conclusions on, 112
-, configuration of orifice
modifies, 107
110
-, depth or hollowness of,
-, diagnosis from attri-
tion, 182
, diagnosis from anae-
mia, 373
, diagnosis from aneu-
rism, 419
— , diastolic ; aortic, 55,
98, 365
mitral, 102
(See case of Goff)
, pulmonic, 57, 80, 101
, tricuspid, 104
, exploration of, 115
, key of, 109, 1 13
, mechanism of, 105
-, musical (see Musical
Murmur)
, pitch of, 109, 113
, practical rules for ex-
ploring, 116
, rough, on what de-
pending, 107
, presumptions afforded
by, 108, 112
} systolic; aortic, 54, 55,
80,96
-, mitral, 80, 101
-, pulmonary , 54 , 55, 80,
100
, tricuspid, 80, 104
, varieties of, 106
. , where best heard, se-
milunar, 114
, auricular, 115
Varix, arterial, causing murmur and thrill,
128
, jugular, a fallacy in aneurism, 429
Vegetations, anatomy of, 349
, causes of, 350
, globular, of Laennec, 484
. , nature of, 59, 211, 350
Vegetations, seat of, 349
(See Valvular Disease.)
Venous hum, 136
Venous murmur, 129
attends inorganic mur-
murs, 373
, causes of, 140
: j described, 130
> distinction from bruit
musculaire, 135
, existing in health, 140
, during pregnancy,
148
> modified by pressure,
131
137
, respiration, 133
■, musical, 136
, proved to be venous,
138
•; physical causes of,
134
-, obstructions to, 132
-, produced by tension,
-j situations of, 132
Venous thrill, 539
(See case of Pyke, Miss JV e.)
Ventricles, diastole of, 43, 84
, causes of, 86
coincides with se-
cond sound, 45, 84
■, duration of, 44
never empty, 43, 45
repose of, 41, 43, 45,84
— , duration of, 44, 87
— , object of, 87
— situation of, 30, 31
—'systole of, 37, 40, 43, 84
, causes which in-
crease, 86
, coincides with
pulse, impulse, and first sound, 44, 84
( duration of, 44
, mechanism of, 85
Vertebrae, effects of aneurisms on, 412*
416
Warts (see Vegetations)
Weight of the heart, 233
Worms in the heart, 340
THE END,
'Hi
mm
ERRATA.
Page 117, last line but one, for distinct point, read distant point.
" 177, 9th line from foot of page,/or completely marked read completely masked.
" 239, in Table VII., last line, for 15 to 59 read 15 to 89.
" 397, Gth line from foot of page,/or concentrive read concentric.
" 429, last line, for an read and.
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